- A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to nd? a. Severe, steady right lower quadrant pain
b. Abdominal pain associated with nausea and vomiting
c. Marked peristalsis and hyperactive bowel sounds
d. Abdominal pain that increases with knee exion
ANS: A
Right lower quadrant pain, specically at McBurney’s point, is characteristic of appendicitis. Usually if nausea and vomiting begin rst, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee exion.
- A nurse cares for an older adult client who has Salmonella food poisoning. The client’s vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete rst?
a. Apply oxygen via nasal cannula.
b. Administer intravenous uids.
c. Provide perineal care with a premedicated wipe.
d. Teach proper food preparation to prevent contamination.
ANS: B
Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so mainte- nance of uid balance is a high priority. Monitoring vital signs and providing perineal care are important nurs- ing actions but are of lower priority than uid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination.
- A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client’s teaching?
a. “Drink plenty of uids to prevent dehydration.”
b. “You should only drink 1 liter of uids daily.”
c. “Increase your protein intake by drinking more milk.”
d. “Sips of cola or tea may help to relieve your nausea.”
ANS: A
The client should drink plenty of uids to prevent dehydration. Milk products may not be tolerated. Caeinated beverages increase intestinal motility and should be avoided
- After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client’s un- derstanding. Which statement made by the client indicates a need for additional teaching?
a. “I will let my husband do all of the cooking for my family.”
b. “I’ll take the cipro oxacin until the diarrhea has resolved.”
c. “I should wash my hands with antibacterial soap before each meal.”
d. “I must place my dishes into the dishwasher after each meal.”
ANS: B
Ciprooxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Sal- monella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year.
- A nurse assesses a client who is hospitalized with an exacerbation of Crohn’s disease. Which clinical manifes- tation should the nurse expect to nd?
a. Positive Murphy’s sign with rebound tenderness to palpitation
b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night
ANS: C
The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn’s disease. A positive Murphy’s sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn’s disease. Nightly worsening of abdominal cramping is not consistent with Crohn’s disease.
- After teaching a client with diverticular disease, a nurse assesses the client’s understanding. Which menu se- lection made by the client indicates the client correctly understood the teaching?
a. Roasted chicken with rice pilaf and a cup of co ee with cream
b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea
c. Garden salad with a cup of bean soup and a glass of low-fat milk
d. Baked sh with steamed carrots and a glass of apple juice
ANS: D
Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-ber foods (cup of bean soup) should be avoided with a low- residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain ber and is acceptable for a low-residue diet.
- A nurse cares for a teenage girl with a new ileostomy. The client states, “I cannot go to prom with an ostomy.” How should the nurse respond?
a. “Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance.”
b. “The pouch won’t be as noticeable if you avoid broccoli and carbonated drinks prior to the prom.”
c. “Let’s talk to the enterostomal therapist about options for ostomy supplies and dress styles.”
d. “You can remove the pouch from your ostomy appliance when you are at the prom so that it is less notice- able.”
ANS: C
The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and car- bonated drinks does not oer reassurance for the client. Ileostomies have an almost constant liquid euent, so pouch removal during the prom is not feasible.
- After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse as- sesses the client’s understanding. Which statement by the client indicates a need for additional teaching?
a. “I’ll rinse my rectal area with warm water after each stool and apply zinc oxide ointment.”
b. “I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel.”
c. “I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry.”
d. “I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.”
ANS: B
Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of supercial abrasions, it is not an eective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating eects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.
- After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assess- es the client’s understanding. Which statement made by the client indicates a need for additional teaching?
a. “I will avoid large crowds and people who are sick.”
b. “I will take this medication with my breakfast each morning.”
c. “Nausea and vomiting are common side e ects of this drug.”
d. “I must wash my hands after I play with my dog.”
ANS: B
Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side eects. Adalimumab can cause im- mune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.
- A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, “I am having trouble swallowing this pill.” Which action should the nurse take?
a. Contact the clinical pharmacist and request the medication in suspension form.
b. Empty the contents of the capsule into applesauce or pudding for administration.
c. Ask the health care provider to prescribe the medication as an enema instead.
d. Crush the pill carefully and administer it in applesauce or pudding.
ANS: C
Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider’s order.
- A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete rst?
a. Inspection of oral mucosa
b. Recent dietary intake
c. Heart rate and rhythm
d. Percussion of abdomen
ANS: C
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mu- cosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.
- A nurse assesses a client with Crohn’s disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
a. Distended abdomen
b. Temperature of 100.0° F (37.8° C)
c. Loose and bloody stool
d. Lower abdominal cramps
ANS: A
The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client’s provider should be notied right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn’s disease.
- A nurse reviews the chart of a client who has Crohn’s disease and a draining stula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?
a. Serum potassium of 2.6 mEq/L
b. Client ate 20% of breakfast meal
c. White blood cell count of 8200/mm3
d. Client’s weight decreased by 3 pounds
ANS: A
Fistulas place the client with Crohn’s disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two ndings are abnormal and also warrant intervention, but the potassium level takes priority.
- After teaching a client who has a new colostomy, the nurse provides feedback based on the client’s ability to complete self-care activities. Which statement should the nurse include in this feedback?
a. “I realize that you had a tough time today, but it will get easier with practice.”
b. “You cleaned the stoma well. Now you need to practice putting on the appliance.”
c. “You seem to understand what I taught you today. What else can I help you with?”
d. “You seem uncomfortable. Do you want your daughter to care for your ostomy?”
ANS: B
The nurse should provide both approval and room for improvement in feedback after a teaching session. Feed- back should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not oer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not oer to teach the daughter instead of the client.
- A nurse assesses a client who is hospitalized for botulism. The client’s vital signs are temperature: 99.8° F (37.6° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take?
a. Decrease stimulation and allow the client to rest.
b. Stay with the client while another nurse calls the provider. c. Increase the client’s intravenous fluid replacement rate.
d. Check the client’s blood glucose and administer orange juice.
ANS: B
A client with botulism is at risk for respiratory failure. This client’s respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse noties the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not re- quire additional intravenous uids. Allowing the client to rest or checking the client’s blood glucose and admin- istering orange juice are not appropriate actions.
- After teaching a client who has diverticulitis, a nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
a. “I’ll ride my bike or take a long walk at least three times a week.”
b. “I must try to include at least 25 grams of ber in my diet every day.”
c. “I will take a laxative nightly at bedtime to avoid becoming constipated.”
d. “I should use my legs rather than my back muscles when I lift heavy objects.”
ANS: C
Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-ber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lift- ing prevents abdominal straining.
- A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?
a. Metronidazole (Flagyl)
b. Cipro oxacin (Cipro)
c. Sulfasalazine (Azul dine)
d. Ceftriaxone (Rocephin)
ANS: A
Metronidazole is the drug of choice for a Giardia infection. Ciprooxacin and ceftriaxone are antibiotics used for bacterial infections. Sulfasalazine is used for ulcerative colitis and Crohn’s disease.
- A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete rst?
a. Heart rate and rhythm
b. Bowel sounds
c. Urinary output
d. Respiratory rate
ANS: D
Severe infection with C. botulinum can lead to respiratory failure, so assessments of oxygen saturation and res- piratory rate are of high priority for clients with suspected C. botulinum infection. The other assessments may be completed after the respiratory system has been assessed.
- A nurse plans care for a client with Crohn’s disease who has a heavily draining stula. Which intervention should the nurse indicate as the priority action in this client’s plan of care?
a. Low- ber diet
b. Skin protection
c. Antibiotic administration
d. Intravenous glucocorticoids
ANS: B
Protecting the client’s skin is the priority action for a client who has a heavily draining stula. Intestinal uid en- zymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn’s disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-ber meals, antibiotic administration, and glucocorticoids.
- A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
a. Pale and bluish stoma
b. Liquid stool
c. Ostomy pouch intact
d. Blood-smeared output
ANS: A
The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.
- A nurse cares for a client with a new ileostomy. The client states, “I don’t think my friends will accept me with this ostomy.” How should the nurse respond?
a. “Your friends will be happy that you are alive.”
b. “Tell me more about your concerns.”
c. “A therapist can help you resolve your concerns.”
d. “With time you will accept your new body.”
ANS: B
Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the client’s concerns or provide false reassurance.
- A nurse cares for a client with ulcerative colitis. The client states, “I feel like I am tied to the toilet. This dis- ease is controlling my life.” How should the nurse respond?
a. “Let’s discuss potential factors that increase your symptoms.”
b. “If you take the prescribed medications, you will no longer have diarrhea.”
c. “To decrease distress, do not eat anything before you go out.”
d. “You must retake control of your life. I will consult a therapist to help.”
ANS: A
Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can in- crease symptoms. These factors should be identied so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may as- sist the client, this is not an appropriate response.
- After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the client’s understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.)
a. “I’ll have my housekeeper keep my toilet clean.”
b. “I must take a shower or bathe every day.”
c. “I should have my well water tested.”
d. “I will ask my sexual partner to have a stool test.”
e. “I must only eat raw vegetables from my own garden.”
ANS: B, C, D
Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual part- ners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointesti- nal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean.
- A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client’s teaching? (Select all that apply.)
a. “Wash leafy vegetables carefully before eating or cooking them.”
b. “Do not ingest water from the garden hose or the pool.”
c. “Wash your hands before and after using the bathroom.”
d. “Be sure meat is cooked to the proper temperature.”
e. “Avoid eating eggs that are sunny side up or undercooked.”
ANS: A, C, D, E
Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not trans- mitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmit- ted by ies, keep ies o of food
-
Chapter 333
-
Chapter 5419
-
Chapter 5523
-
Chapter 5629
-
Chapter 5729
-
Chapter 5825
-
Chapter 5925
-
PRACTICE50
-
Alzheimers Disease3
-
Parkinsons disease27
-
lewis: hedache seizures26
-
Chapter 44: iggy22
-
Chapter 66; Brunner headache seizures17
-
Resource 166
-
Select all15
-
Eye review78
-
Final Review- Eye/Ear54
-
Final Review- Blood16
-
Final Review- Old stuff42
