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 D

Explanation

The patient has been diagnosed with type 2 diabetes and reports following a reduced-calorie diet but has not lost any weight. This suggests that the patient may not be following the diet as prescribed or may have other factors aﬀecting their blood glucose levels. Additionally, the patient did not bring their glucose monitoring record, which is an important tool for assessing blood glucose control over time.

In this situation, obtaining a fasting blood glucose level or an oral glucose tolerance test may provide a snapshot of the patient's blood glucose level at the time of the test, but these tests do not provide information about blood glucose control over the past few months. A urine dipstick for glucose is a less reliable method for assessing blood glucose control and is not recommended for routine monitoring.

Therefore, obtaining a glycosylated hemoglobin (HbA1c) level is the most appropriate test in this situation. HbA1c reﬂects the average blood glucose level over the past 2-3 months and is recommended for routine monitoring of blood glucose control in patients with diabetes. This test can provide valuable information about the eﬀectiveness of the patient's diet and any other interventions aimed at controlling their blood glucose levels.

A. The client's stool is positive for occult blood. B. The client reports abdominal discomfort an hour after each meal. C. The client has had four ulcers in the last 5 years. D. The client's hemoglobin is 13 g/dL and hematocrit is 42%.

Correct Answer is B

Explanation

Abdominal discomfort an hour after a meal is a common symptom of a gastric ulcer because the stomach is where food is initially processed, and stomach acid is most concentrated. In contrast, duodenal ulcers typically cause pain 2-3 hours after meals, as food moves out of the stomach and into the duodenum, where it encounters duodenal acid.

A positive stool occult blood test is a non-specific finding that can be caused by many gastrointestinal conditions, including peptic ulcers. It does not indicate the location of the ulcer.

The number of ulcers the client has had in the past does not indicate the location of the current ulcer.

Normal hemoglobin and hematocrit levels do not provide information about the location of the ulcer.

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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

During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n)

Correct Answer is D

Explanation

The nurse is caring for a client with diagnosis of peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than the duodenum?

Correct Answer is B

Explanation

A nurse is preparing a client for discharge home who is confused and incontinent after a stroke. Which instructions regarding bladder training will the nurse include in the teaching plan for the client's family?

The physical environment and traffic control measures of the operating room are designed primarily to:

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