When providing nursing care for a client after a gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?
Sore throat.
Headache.
Aching leg.
Nausea.
The Correct Answer is A
Choice A rationale
After a gastric endoscopy, it’s common for patients to experience a sore throat. This is due to the passage of the endoscope through the throat during the procedure. The discomfort is usually temporary and can be relieved with lozenges or gargling with warm salt water.
Choice B rationale
While headaches can occur after procedures that involve sedation, they are not commonly associated with gastric endoscopy specifically. Therefore, while it’s important to monitor for headaches, they are not a typical post-procedure problem following a gastric endoscopy.
Choice C rationale
Aching legs are not a common problem following a gastric endoscopy. The procedure primarily involves the upper gastrointestinal tract, and does not directly affect the legs.
Choice D rationale
Nausea can occur after a gastric endoscopy, but it is more commonly associated with the sedation used during the procedure rather than the procedure itself. If nausea does occur, it can be managed with antiemetic medications.
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Correct Answer is D
Explanation
Choice A rationale
While switching to less anxiety-provoking questions might help in some situations, it does not address the immediate issue of the client undressing inappropriately.
Choice B rationale
Ignoring the client’s inappropriate behavior could potentially encourage further inappropriate actions and does not respect the therapeutic boundaries necessary in a nurse-client relationship.
Choice C rationale
Leaving the client’s room might escalate the situation further and does not address the immediate issue.
Choice D rationale
The nurse should assertively but respectfully communicate that undressing is not appropriate during the interview. This sets clear boundaries and expectations for the client’s behavior.
Correct Answer is B
Explanation
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the patient’s joint pain, it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice B rationale
Infusing an intravenous fluid bolus is the first intervention that should be implemented in an acute adrenal crisis. This can help to increase the patient’s blood pressure, which is dangerously low.
Choice C rationale
Administering a PRN oral antipyretic could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice D rationale
Covering the patient with a cooling blanket could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
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