Question

A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

Answer 1

Correct Answers:

Relief of heartburn

Rationale :

H2 receptor antagonists (H2RAs) reduce stomach acid production, making them effective for treating conditions like gastroesophageal reflux disease (GERD), peptic ulcers, and heartburn. By blocking histamine in the stomach lining, they decrease acid secretion, leading to symptom relief. Common H2RAs include ranitidine (withdrawn), famotidine, and cimetidine.

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Answer 2

Correct Answers:

Lower the client to the floor.

Rationale :

If a client starts falling, the nurse should protect them from injury by guiding them safely to the ground. This is done by supporting the client’s weight, bending the knees, and gently lowering them while keeping the back straight. This technique prevents sudden impact and minimizes injury risk for both the nurse and client.

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Answer 3

Correct Answers:

Tempeh

Rationale :

Vitamin B12 is primarily found in animal products, so vegans need alternative sources. Tempeh, a fermented soybean product, contains B12 due to bacterial fermentation. However, supplementation is often recommended since plant-based sources are inconsistent.

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Answer 4

Correct Answers:

Test the pH of gastric aspirate.

Rationale :

Before administering an enteral feeding, the nurse must verify NG tube placement to prevent aspiration. Checking gastric pH (should be ≤5.5) ensures the tube is in the stomach. Incorrect placement can lead to serious complications like aspiration pneumonia.

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Answer 5

Correct Answers:

Increased calcium excretion

Rationale :

Prolonged immobility leads to bone demineralization, causing increased calcium excretion (hypercalciuria) and increasing the risk of osteoporosis and kidney stones. Weight-bearing activity is essential to maintain bone density.

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Answer 6

Correct Answers:

Urine output of 175 mL in the past 8 hr

Rationale :

Normal urine output should be at least 30 mL/hr. A low output (oliguria) suggests impaired kidney function and requires immediate intervention to prevent acute kidney injury.

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Answer 7

Correct Answers:

Ask the client to push her feet against the nurse's palms.

Rationale :

Assessing muscle strength requires active resistance testing. Having the client push against resistance evaluates lower extremity strength and readiness for ambulation.

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Answer 8

Correct Answers:

Loss of urine when laughing, coughing, sneezing

Rationale :

This describes stress incontinence, which occurs due to weakened pelvic floor muscles that fail to support the bladder under pressure. It is common in postpartum women and older adults.

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Answer 9

Correct Answers:

Client has soft, unpigmented hair on arms.
Client reports consuming around 600 calories each day
Client reports preoccupation with thoughts about food.
Client voices being "too tired" and lacks interest in daily workouts at the gym.
Client's hair appears brittle and thin.

Rationale :

Anorexia nervosa is characterized by extreme weight loss, distorted body image, and severe dietary restriction. Key signs include lanugo (fine hair growth), calorie restriction, preoccupation with food, fatigue, and brittle hair.

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Answer 10

Correct Answers:

Exposure to sunlight

Rationale :

Sunlight triggers vitamin D synthesis in the skin, which is essential for calcium absorption and bone health. Without sun exposure, vitamin D deficiency can occur, leading to rickets or osteomalacia.

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QLexNursing

1 : A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

2 : A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

3 : A nurse is providing teaching to a client who is pregnant and is vegan. The nurse should instruct the client that which of the following foods is a reliable source of Vitamin B12?

4 : A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

5 : A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

6 : A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

7 : A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

8 : A patient presents with urinary incontinence. Which of the following expected findings would the nurse most likely assess?

9 : A nurse is caring for a 19-year-old client in the emergency department who reports passing out while at school.

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10 : A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following is a trigger for the formation of vitamin D in the body?