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 B

Explanation

The statement "I had the stomach ﬂu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.

Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.

The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.

A. 5.0 mEq/L B. 2.9 mEq/L C. 3.8 mEq/L D. 6.0 mEq/L

Correct Answer is B

Explanation

Furosemide is a loop diuretic that works by blocking the reabsorption of sodium and chloride in the ascending loop of Henle in the kidney, leading to increased urine output. However, this medication can also cause potassium loss through increased urinary excretion, which can lead to hypokalemia (low potassium level). Hypokalemia can cause confusion, weakness, and other neurological symptoms.

The normal range for serum potassium is 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L is below the normal range and is considered hypokalemic. Therefore, the nurse should correlate the client's confusion with the low potassium level and notify the healthcare provider to adjust the medication or provide potassium supplements if indicated.

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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 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:

Correct Answer is B

Explanation

A client is taking furosemide (Lasix), a diuretic. and becomes confused. Which potassium level does the nurse correlate with this condition?

Correct Answer is B

Explanation

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