When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

Breath sounds.

abdominal girth.

Bowel sounds.

Apical pulse.

Answer and Explanation

The Correct Answer is A

GERD can increase the risk of aspiration (inhalation of stomach contents into the lungs), which can cause respiratory issues, including abnormal breath sounds. In these cases, monitoring of breath sounds may be more appropriate than monitoring of bowel sounds.

Bowel sounds are not typically monitored for GERD patients as GERD is a condition that aﬀects the esophagus and the stomach, not the intestines. GERD is caused by the reﬂux of stomach contents into the esophagus, which can cause symptoms such as heartburn and regurgitation.

Abdominal girth is not routinely monitored for GERD patients as it is not typically related to the condition. GERD is a disorder that aﬀects the esophagus and stomach and does not typically cause significant changes in abdominal size or girth. In rare cases, GERD can be complicated by a condition known as a para oesophageal hernia, which can cause a visible bulge in the abdomen. In these cases, monitoring of abdominal size and shape may be necessary.

The apical pulse is not routinely monitored for GERD patients as it is not directly related to the condition. GERD is a disorder that aﬀects the digestive system, specifically the esophagus and stomach and does not typically have an impact on heart rate or rhythm.

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Correct Answer is A

Explanation

acromegaly typically causes an enlargement of the hands and feet. The nurse can inquire if the patient has noticed any changes in shoe size, as this may indicate abnormal growth.

"Are you experiencing tremors or anxiety" is not directly related to acromegaly, and although anxiety can be associated with some medical conditions, it is not a typical symptom of acromegaly.

"Is there any family history of acromegaly?" is also a relevant question, as acromegaly can be caused by a genetic disorder. If the patient has a family history of the condition, this may increase their risk of developing it.

"Have you had a recent head injury?" is not specifically related to acromegaly, although head trauma can cause a variety of medical conditions.

Overall, option a. is the most relevant question to ask a patient with suspected acromegaly.

A. Decreasing serum sodium B. Decreasing blood glucose C. Decreasing serum potassium D. Increasing urinary output

Correct Answer is D

Explanation

One of the hallmarks of adrenal insufficiency is dehydration and decreased urinary output, which can lead to electrolyte imbalances such as hyperkalemia and hyponatremia. As treatment begins to take eﬀect, the patient's ﬂuid and electrolyte balance should improve, leading to an increase in urinary output. Acute adrenal insufficiency, also known as the Addisonian crisis, is a life-threatening condition caused by a sudden decrease in cortisol and aldosterone hormones. Treatment usually involves the administration of intravenous glucocorticoids and mineralocorticoids to replace the deficient hormones.
Decreasing serum sodium (a) and decreasing blood glucose (b) are not signs of improvement but rather indicative of continued adrenal insufficiency. Decreasing serum potassium (c) is also not a sign of improvement as it could indicate that the patient is developing hyperkalemia, which is a potential complication of adrenal crisis.

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When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

Correct Answer is A

Explanation

A patient is hospitalized with acute adrenal insufficiency. The nurse determines that the patient is responding favorably to treatment on finding:

Correct Answer is D

Explanation

A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?

A patient is taking high doses of prednisone to control the symptoms of acute exacerbation of systemic lupus erythematosus. When teaching the patient about the use of prednisone, which information is important for the nurse to include?

Which information will the nurse include when teaching a patient with newly diagnosed GERD?

A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will:

A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

The nurse is creating the care plan for a patient with symptoms of DI who was admited to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is: