The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which finding would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct.
Excessive salivation
Dyspepsia
Regurgitation
Blood-tinged sputum
Flatulence
Correct Answer : B,C,E
Choice A Reason:
Excessive salivation, also known as water brash, can occur in some cases of GERD, but it is not one of the most common symptoms. Water brash happens when the body produces extra saliva to neutralize the acid in the esophagus. While it can be associated with GERD, it is not as prevalent as other symptoms like heartburn or regurgitation.
Choice B Reason:
Dyspepsia, or indigestion, is a common symptom of GERD. It includes discomfort or pain in the upper abdomen, bloating, and nausea. Dyspepsia occurs because the stomach acid irritates the lining of the esophagus and stomach, leading to these uncomfortable sensations. Therefore, dyspepsia is a typical finding in patients with GERD.
Choice C Reason:
Regurgitation is a hallmark symptom of GERD. It involves the backflow of stomach contents into the esophagus and sometimes into the mouth, causing a sour or bitter taste. This symptom is due to the weakening or relaxation of the lower esophageal sphincter, which allows stomach acid to escape into the esophagus.
Choice D Reason:
Blood-tinged sputum is not a common symptom of GERD. While severe cases of GERD can lead to complications such as esophagitis or esophageal ulcers, which might cause bleeding, this is not typical in most GERD cases. Blood-tinged sputum would warrant further investigation to rule out other conditions such as infections or malignancies.
Choice E Reason:
Flatulence, or excessive gas, can be associated with GERD. The digestive process can be affected by the reflux of stomach acid, leading to increased gas production and bloating. While not as prominent as dyspepsia or regurgitation, flatulence can still be a symptom experienced by patients with GERD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Monitoring the heart rate is crucial when administering amiodarone, as this drug can cause bradycardia (a slower than normal heart rate). Amiodarone affects the electrical conduction system of the heart, and close monitoring helps ensure that the heart rate remains within a safe range. The normal resting heart rate for adults is typically between 60 and 100 beats per minute.
Choice B reason: Respiratory rate monitoring is essential because amiodarone can cause pulmonary toxicity, which may manifest as interstitial pneumonitis or pulmonary fibrosis. Early detection of respiratory changes can help prevent severe complications. The normal respiratory rate for adults is 12 to 20 breaths per minute.
Choice C reason: Monitoring heart rhythm is necessary because amiodarone is used to treat arrhythmias, and it can also cause new arrhythmias or exacerbate existing ones. Continuous ECG monitoring helps detect any abnormal rhythms early, allowing for prompt intervention. Normal sinus rhythm is characterized by a regular rhythm with a rate of 60 to 100 beats per minute.
Choice D reason: Cardiac output monitoring is important because amiodarone can affect the contractility of the heart and overall cardiac function. Cardiac output is a measure of the amount of blood the heart pumps in one minute, and it is crucial for ensuring adequate tissue perfusion. Normal cardiac output ranges from 4 to 8 liters per minute in adults.
Correct Answer is ["B","C","E"]
Explanation
Choice A: Lean on your back with your knees bent.
Reason: This instruction is incorrect. Pursed lip breathing is typically performed in a seated position with the neck and shoulders relaxed. Lying on your back with knees bent is not a recommended position for this breathing technique.
Choice B: Use your abdominal muscles to squeeze air out of your lungs.
Reason: This instruction is correct. Using the abdominal muscles helps to expel air more effectively from the lungs, which is a key component of pursed lip breathing. This technique helps to improve ventilation and reduce the work of breathing.
Choice C: Breathe out slowly without puffing your cheeks.
Reason: This instruction is correct. Breathing out slowly through pursed lips without puffing the cheeks helps to keep the airways open longer, allowing more air to be expelled from the lungs. This technique is particularly beneficial for individuals with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice D: Focus on inhaling and holding your breath as long as you can.
Reason: This instruction is incorrect. The focus of pursed lip breathing is on controlled exhalation rather than holding the breath. Inhaling should be done slowly through the nose, and exhaling should be prolonged through pursed lips.
Choice E: Exhale at least twice the amount of time it took to breathe in.
Reason: This instruction is correct. The exhalation phase should be longer than the inhalation phase, typically taking at least twice as long. This helps to improve the efficiency of breathing and reduce shortness of breath.
Choice F: Open your mouth and breathe deeply.
Reason: This instruction is incorrect. Pursed lip breathing involves breathing in through the nose and exhaling through pursed lips. Opening the mouth and breathing deeply is not part of this technique.
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