Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream.
Suggest that the client also plan to eat frequent small meals to reduce discomfort.
Remind the client that it is also important to switch to decaffeinated coffee and tea.
Reinforce the teaching by asking the client to make a list of snack foods high in dairy content.
The Correct Answer is A
Choice A rationale
Reviewing with the client the need to avoid foods rich in milk and cream is crucial. Dairy products can increase gastric acid secretion, which can exacerbate duodenal ulcers.
Choice B rationale
Suggesting frequent small meals can help reduce discomfort but does not address the issue of dairy products exacerbating the ulcer.
Choice C rationale
Switching to decaffeinated coffee and tea is beneficial but not as critical as avoiding dairy products.
Choice D rationale
Reinforcing teaching by asking the client to list dairy foods does not address the need to avoid these foods.
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Correct Answer is A
Explanation
Choice A rationale
Asking the client to describe the pain is the best approach to assess the quality of pain. This allows the nurse to gather detailed information about the pain’s characteristics.
Choice B rationale
Identifying effective pain relief measures is important but does not directly assess the quality of pain.
Choice C rationale
Observing body language and movement can provide clues about pain but is not as effective as directly asking the client to describe the pain.
Choice D rationale
Providing a numeric pain scale helps quantify the pain but does not provide detailed information about the pain’s quality.
Correct Answer is D
Explanation
Choice A rationale
Counting the apical and radial pulses simultaneously is important for assessing pulse deficits, but it is not the most critical assessment for a client receiving hydromorphone.
Choice B rationale
Measuring the client’s capillary glucose level is important for clients with diabetes, but it is not directly related to the administration of hydromorphone.
Choice C rationale
Observing for edema around the ankles is important for assessing fluid retention, but it is not the most critical assessment for a client receiving hydromorphone.
Choice D rationale
Auscultating the client’s bowel sounds is crucial because hydromorphone is a potent opioid analgesic that can slow peristalsis and frequently causes constipation. Monitoring bowel sounds helps prevent complications such as bowel obstruction. .