Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?
Monitor daily urine output volume.
Use salt tablets after strenuous exercise.
Review food labels for sodium content.
Drink plenty of water whenever thirsty.
The Correct Answer is C
Choice A rationale
Monitoring daily urine output volume is important for assessing fluid balance, but it does not directly address the issue of hypernatremia. Hypernatremia is characterized by high sodium levels in the blood, and monitoring urine output alone will not help in managing sodium intake or identifying sources of excess sodium.
Choice B rationale
Using salt tablets after strenuous exercise is not recommended for clients with hypernatremia. Salt tablets can increase sodium levels further, exacerbating the condition. Hypernatremia requires careful management of sodium intake, and salt tablets would be counterproductive.
Choice C rationale
Reviewing food labels for sodium content is crucial for clients with hypernatremia. This helps them identify and avoid foods high in sodium, which can contribute to elevated sodium levels in the blood. Educating clients on reading food labels empowers them to make informed dietary choices and manage their condition effectively.
Choice D rationale
Drinking plenty of water whenever thirsty is a general recommendation for maintaining hydration, but it does not specifically address hypernatremia. Clients with hypernatremia need to focus on managing their sodium intake and ensuring they do not consume excessive amounts of sodium.
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Correct Answer is A
Explanation
Choice A rationale
Hematemesis, or vomiting blood, is a critical sign of bleeding esophageal varices, which can be life-threatening. Clients with chronic cirrhosis and esophageal varices are at high risk for variceal bleeding due to increased portal hypertension. Monitoring for hematemesis is essential to provide timely intervention and prevent complications.
Choice B rationale
Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice C rationale
Clay-colored stool indicates a lack of bile in the stool, which can occur in liver disease. However, it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice D rationale
Brown, foamy urine can be a sign of liver dysfunction, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Correct Answer is A
Explanation
Choice A rationale
The severity of nausea and vomiting and serum amylase results are crucial in diagnosing and managing pancreatitis. Elevated serum amylase levels are a key indicator of pancreatitis, and the severity of nausea and vomiting can help assess the patient’s condition and response to treatment.
Choice B rationale
Reports of chronic constipation and serum gastrin levels are not directly related to the acute management of pancreatitis. Chronic constipation is more associated with gastrointestinal motility disorders, and serum gastrin levels are typically measured in conditions like Zollinger-Ellison syndrome.
Choice C rationale
Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly relevant to the acute management of pancreatitis. H. pylori is associated with peptic ulcer disease, and urine output is more relevant in assessing renal function.
Choice D rationale
The presence of bowel sounds and the degree of abdominal pain are important but not as specific as serum amylase levels in diagnosing pancreatitis. Bowel sounds can be affected by various conditions, and abdominal pain is a common symptom in many gastrointestinal disorders.