Health Assessment: Rashid Ahmed Post-Simulation Quiz
Mr. Ahmed is being considered for discharge after being successfully treated for nausea, vomiting, and diarrhea associated with gastroenteritis. Which assessment data best supports the success of his treatment? Good toleration of oral antibiotic therapy Normal skin turgor Active bowel sounds present in all quadrants Voiding adequate amounts of yellow urine
Active bowel sounds present in all quadrants Rationale: Diarrhea, a primary sign associated with gastroenteritis, presents with hyperactive bowel sounds. Assessment data indicating normally active bowel sounds in all abdominal quadrants would indicate that the patient is responding to treatment. Antibiotic treatment is often incorporated, but toleration of the medication can be affected by a variety of administration routes. The remaining options are primarily associated with dehydration, which is a comorbid condition that can be associated with gastroenteritis.
Mr. Ahmed's diagnosis of gastroenteritis has been treated with antibiotic therapy. Which assessment data best supports the effectiveness of this therapy? Heart rate is 92 beats per minute and regular Oral temperature is 36.6°C (97.8°F) Patient is drinking moderate amounts of clear liquids Abdomen is soft
Oral temperature is 36.6°C (97.8°F) Rationale: Effective antibiotic therapy would result in an absence of fever. The other options are not as directly associated with infection control but rather dehydration.
Which nursing interventions would provide appropriate support for a patient being treated for a bacterial infection? (Select all that apply.) Regularly monitoring and recording temperature Maintaining a cool room temperature Implementing seizure precautions Providing appropriate clothing and bed coverings to prevent overheating Encouraging fluid and nutritional intake as tolerated
Regularly monitoring and recording temperature Providing appropriate clothing and bed coverings to prevent overheating Encouraging fluid and nutritional intake as tolerated Rationale: The monitoring of temperature, encouraging fluid and food intake as tolerated, and preventing overheating are all appropriate, supportive nursing measures for a patient experiencing a bacterial infection. A cool environment may encourage chills, which would serve to increase the patient's temperature. Seizures are more likely to occur in children, who experience extremely high fevers.
Which intervention is focused on assuring a patient's cooperation and minimizing the patient's concerns while gathering subjective information during an abdominal assessment? (Select all that apply.) Gathering all necessary equipment prior to beginning the assessment Placing the patient in a comfortable and assessable position Providing an explanation of why personal questions will be asked Performing appropriate handwashing before touching the patient Asking questions in a matter-of-fact manner
Asking questions in a matter-of-fact manner Providing an explanation of why personal questions will be asked Rationale: Subjective information is data that can only be elicited and verified by the patient. Since the questioning can be embarrassing, the nurse should be attentive to educating the patient to why such questioning is necessary and to ask the questions in a non-biased, matter-of-fact manner. The other options are directed toward the gathering of objective data during the abdominal assessment.
Mr. Ahmed has been diagnosed with gastroenteritis. Which of his assessment findings are directly associated with an improvement in this condition? (Select all that apply.) Bowel sounds heard in all four quadrants Hypoactive bowel sounds present Tolerating small amounts of clear liquids Voiding without difficulty Abdomen soft
Bowel sounds heard in all four quadrants Tolerating small amounts of clear liquids Abdomen soft Rationale: Gastroenteritis is the self-limiting inflammation of the stomach and small intestine. Abdominal pain, vomiting, and diarrhea are the primary resulting symptomatology. Dehydration is a complication of gastroenteritis. Bowel sounds in all quadrants and a soft, nondistended abdomen are objective signs that indicate improvement. The ability to tolerate small amounts of liquids without experiencing nausea and vomiting is also a positive event. Voiding without difficulty is associated with the complication of dehydration, whereas hypoactive bowel sounds are not associated with either gastroenteritis or normal gastrointestinal functioning.
A patient diagnosed with gastroenteritis has reported dizziness when standing up from a sitting position. What information will the nurse provide to the patient to best explain the need to monitor all fluid intake and urinary output? Dehydration may be causing your dizziness, so it's important to monitor the balance of fluids in your body. The dizziness can be related to your gastroenteritis and the vomiting and diarrhea you have been experiencing. It's important to measure both the fluids you drink and the urine you produce so that we can identify if there is an imbalance. You are feeling dizzy when you stand up because you are not taking in more fluid than you are putting out in urine.
Dehydration may be causing your dizziness, so it's important to monitor the balance of fluids in your body. Rationale: The patient's diagnosis is characterized with vomiting and diarrhea, both of which contribute to a fluid imbalance. Orthostatic hypotension is related to such a fluid imbalance. A standard intervention is the monitoring of both intake and output to assess for possible dehydration and direct its treatment. While the remaining options are correct statements, they do not educate the patient about the cause and treatment of the problem.
Mr. Ahmed has demonstrated improvement after treatment was implemented 48 hours ago for dehydration associated with gastroenteritis. Which discharge instruction will the nurse provide to best help resolve his original report of dizziness? Take frequent rests until you regain your strength and the weakness lessens Get up from a lying or sitting position slowly, being careful to support yourself as you begin to walk Avoid drinking alcohol in any form for at least the next 48 to 72 hours Drink fluids every 15 to 30 minutes, increasing the amount as your tolerance improves
Drink fluids every 15 to 30 minutes, increasing the amount as your tolerance improves Rationale: A common cause of dizziness associated with gastroenteritis is dehydration. Rehydrating with frequent, small amount of oral fluids will help reestablish blood volume and resolve the dizziness. While the other options are appropriate, they are not directed toward correcting the problem but rather minimizing the risk of injury or, in the case of the alcohol, preventing it from negatively affecting the treatment.
A patient has been treated for diarrhea and vomiting, which has caused dehydration and hypokalemia. Which assessment data will confirm that the IV administration of potassium has been effective? Patient denies nausea or abdominal pain Skin is dry and demonstrates good turgor Normal bowel sounds are in all quadrants Heart rate is 86 beats per minute, with regular rhythm
Heart rate is 86 beats per minute, with regular rhythm Rationale: IV fluid and potassium administration is appropriate for this patient. Hypokalemia can result in cardiac dysrhythmias and even cardiac arrest. Effective treatment would demonstrate a pulse that is normal in rate (60 to100 beats per minute), rhythm, and strength. The remaining options suggest that dehydration is resolved, but are not indications that the hypokalemia is resolved.
An older adult patient being treated for gastroenteritis-induced dehydration and hypokalemia is now being assessed for discharge. Which assessment findings will confirm the effectiveness of the treatment? (Select all that apply.) Patient reports abdominal pain as 1 out of 10 24-hour fluid intake is 1700 mL, and fluid output is 1950 mL Serum potassium level is 3.2 mEq/L Patient has one semi-formed stool in the last 12 hours Mucous membranes appear moist
Mucous membranes appear moist Patient has one semi-formed stool in the last 12 hours Patient reports abdominal pain as 1 out of 10 24-hour fluid intake is 1700 mL, and fluid output is 1950 mL Rationale: The loss of body fluids associated with gastroenteritis can trigger both dehydration and hypokalemia. As a result, mucous membranes become dry, urine output and fluid intake drop, frequent diarrhea occurs, and abdominal pain is present. Improvement or elimination of these signs and symptoms demonstrate an effective plan of care. Potassium levels drop as a result of vomiting and diarrhea. A level within the normal range, between 3.5 and 5 mEq/L, would indicate successful resolution of hypokalemia.
Which patient statement supports that dehydration-related orthostatic hypotension is being resolved with treatment? Being dehydrated can make you feel dizzy. I sit for a moment on the edge of the bed before getting up to walk. Now that my dizziness is gone, I feel so much safer about getting up and walking. I've been drinking more fluid with my meals.
Now that my dizziness is gone, I feel so much safer about getting up and walking. Rationale: Dizziness associated with orthostatic hypotension can be a result of dehydration. The patient's statement concerning safer mobility indicates that the dizziness is resolving or is no longer an issue. The remaining options either relate to rehydration, effects of dehydration, or precautions taken to minimize the effects of orthostatic hypotension.
