Adult 1 - Exam 3

The nurse is preparing to assess a new client who has class III obesity. In order to provide empathic and holistic care for this client, the nurse should first:

examine their own preconceptions and beliefs about obesity.

An adult female client has a body mass index of 34.5 kg/m2 and has expressed interest in bariatric surgery. What characteristic of the client's health status may exclude her from being an appropriate surgical candidate?

The client drinks six to eight cans of beer daily

A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?

Change in bowel habits

The nurse has completed the admission assessment of a client and has determined that the client's body mass index (BMI) is 33.5 kg/m2. What health promotion advice should the nurse provide to the client?

"It would be very helpful if you could integrate more physical activity into your routine."

A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this client's health problem?

"The enzymes that your pancreas produces have damaged the pancreas itself."

A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which of the following clients as having the highest risk for chronic pancreatitis?

A 39-year-old man with chronic alcoholism

A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care?

Assessment for variceal bleeding

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery?

Bile duct injury

A client who is recovering from bariatric surgery reports a rapid onset of nausea, bloating, and cramping after eating a meal. The nurse's assessment reveals diaphoresis and a heart rate of 98 beats per minute. What assessment should the nurse prioritize once the client's immediate symptoms resolve?

Capillary blood glucose

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?

Contact the primary provider promptly and report these signs of perforation

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

Daily weights and abdominal girth measurement

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis?

Foul-smelling diarrhea that contains fat

A client has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the client is most likely to require which of the following?

Hospice care

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.

Increased fiber intake Reduced fat intake

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize?

Ineffective Tissue Perfusion Related to Bowel Ischemia

A 35-year-old male client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary provider, what intervention should the nurse prioritize?

Insertion of a nasogastric tube

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

Two to three soft bowel movements daily

The nurse is speaking with a 20-year-old client who has class II obesity. The client states, "No matter what I do, I can't lose weight. How soon do you think I could get bariatric surgery?" What is the nurse's best response?

"Bariatric surgery is often very effective, but it usually happens after a lengthy process of consultations and referrals."

A client with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the client states:

"I will take this medication for 2 weeks and then gradually stop taking it."

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal?

Client will accurately identify foods that trigger symptoms.

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine?

An immune globulin injection

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace?

Disposing of sharps appropriately and not recapping needles

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

Immunization Use of standard precautions

The nurse is admitting a client with traumatic injuries who also has class III obesity. When planning this client's care, the nurse should address the client's heightened risk of what nursing diagnoses related to obesity? Select all that apply.

Impaired skin integrity Impaired gas exchange

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods?

Low-fat foods high in proteins and carbohydrates

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?

"How many alcoholic drinks do you typically consume in a week?"

A client with obesity has been taking orlistat for the past several days. During the client's most recent follow-up assessment with the nurse, the client states, "I'm embarrassed to even say it, but I've had a few episodes of leaking stool since I've started this medication." What is the nurse's best response?

"That sounds stressful for you. That's definitely one of the adverse effects of this medication."

A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply.

Administering diuretics Implementing fluid restrictions Enhancing client positioning

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan?

Administration of diuretics as prescribed

A client's physician has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.

Alanine aminotransferase (ALT) Gamma-glutamyl transferase (GGT) Aspartate aminotransferase (AST)

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function?

Consume high-residue, high-fiber foods

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Fried chicken

A client with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the client should be informed that this procedure will involve the removal of which of the following? Select all that apply.

Gallbladder Part of the stomach Duodenum Part of the common bile duct

A client presents to the emergency department (ED) complaining of severe right upper quadrant pain. The client states that his family doctor told him he had gallstones. The ED nurse should recognize what possible complication of gallstones?

Gangrene of the gallbladder

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate?

Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes?

Maintaining fluid and electrolyte balance

A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery?

Malabsorption and hyperglycemia

The nurse is performing a health assessment of a client who has been taking antiobesity medications for several weeks. During the nurse's gastrointestinal assessment, the client reports bowel movements described as "greasy" and "oily." What medication is the client most likely taking?

Orlistat

A client who is recovering from bariatric surgery has not had a bowel movement for 48 hours and bowel sounds are absent on auscultation. The nurse has informed the on-call health care provider who has prescribed insertion of a nasogastric tube to low suction. What is the nurse's best action?

Question the order due to the client's recent bariatric surgery

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response?

Report this finding to the primary provider due to the possibility of hepatic encephalopathy.

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region?

Right shoulder

A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis?

Risk for Infection Related to Possible Rupture of Appendix

A nurse is assessing an elderly client with gallstones. The nurse is aware that the client may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly client may include what?

Signs and symptoms of septic shock

A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem?

The client's polyps constitute a risk factor for cancer

A nurse is caring for a client who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this client, the nurse should describe what aspect of this diagnostic procedure?

The use of moderate sedation

A nurse is preparing to provide care for a client whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the client's stools will have what characteristics?

Watery with blood and mucus