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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Kegel exercises are designed to strengthen the pelvic floor muscles, which can help improve urinary incontinence. By teaching the patient how to perform Kegel exercises, the nurse can provide a non-invasive, effective intervention that the patient can perform on her own to help manage her urinary incontinence.
Assisting the patient to the bathroom q3hr (b) may help reduce the frequency of incontinence episodes but it does not address the underlying issue of weakened pelvic floor muscles.
Demonstrating how to perform Crede’s maneuver (c) involves applying manual pressure to the bladder to assist with urination and is not appropriate for managing urinary incontinence related to laughing or coughing.
Placing a commode at the patient’s bedside (d) may be appropriate for patients who have difficulty with mobility or accessing the bathroom, but it does not address the underlying issue of weakened pelvic floor muscles causing urinary incontinence.
Correct Answer is A
Explanation
The first step in the education plan should be to assess their understanding and perception of the disease. This will help the nurse to identify any misconceptions or knowledge gaps that the patient may have and tailor the education plan accordingly. Understanding the patient's perceptions will also help the nurse to establish a trusting relationship with the patient and increase their engagement in diabetes self-management.
Options b, c, and d are important components of the diabetes education plan, but they should be implemented after the initial assessment of the patient's perception and understanding of their diagnosis.
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