NUR 322 - prepU exam 1 material
Loss of motor control of the detrusor muscle
A nurse who is taking care of a patient with a spinal cord injury documents the frequency of reflex incontinence. The nurse understands that this is most likely due to:
stool consistency and client comfort
An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"?
Detects calculi, cysts, or tumors
An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale?
Decreased abdominal strength
An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients?
Incontinence
Which type of voiding dysfunction is seen in clients diagnosed with Parkinson disease?
- fever - abdominal distention - sudden, sustained abdominal pain
The nurse is caring for a client with a mechanical intestinal obstruction who is at risk for perforation. For which finding(s) should the nurse monitor the client? Select all that apply.
One part of the intestine telescopes into another portion of the intestine
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
Location of discomfort
The nurse performs a physical examination on a client diagnosed with acute pyelonephritis to assist in determining which of the following?
solid
The nurse teaches the client whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be
Diabetes mellitus
A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following?
Urge
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?
Acute pain
A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?
Kidney
A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
White blood cell (WBC) count 22.8/mm3
A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately?
Potassium-rich foods
A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?
Steatorrhea
A client is diagnosed with Zollinger-Ellison syndrome. The nurse knows to assess the client for which characteristic clinical feature of this syndrome?
Assessing present voiding patterns
A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?
"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?
Increasing fluid intake to prevent dehydration
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of?
Ulcerative colitis
A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem?
The client's natural bowel function may become sluggish
A client realizes that regular use of laxatives has greatly improved bowel patterns. However, the nurse cautions this client against the prolonged use of laxatives for which reason?
They can be habit forming and will require increasing doses to be effective.
A client reports taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?
Maintain skin and stoma integrity
A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. Which postoperative procedure should the nurse perform?
"Make sure to eat enough fiber to prevent constipation."
A client with urinary incontinence asks the nurse for suggestions about managing this condition. Which suggestion would be most appropriate?
type and size of the catheter to be used
A client with urinary retention needs to undergo a procedure to insert an indwelling catheter. What should the nurse discuss with the health care provider before catheterization?
"This medication will relieve your pain."
A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Which of the following instructions would the nurse give the client?
- Suspend the drainage bag off the floor. - Empty the collection bag at least every 8 hours to reduce bacterial growth. - Wash the perineal area with soap and water at least twice daily.
A major goal when caring for a catheterized patient is to prevent infection. Select all the nursing actions that apply.
Infection
A nurse caring for a patient with a neurogenic bladder knows to assess for the major complication of:
Acyclovir
A nurse is caring for a client admitted with symptoms of an anorectal infection; cultures indicate that the client has a viral infection. The nurse should anticipate the administration of what drug?
The client exhibits signs of adequate GI perfusion
A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control?
By ascending infection (transurethral)
A nurse is conducting a health history on a patient who is seeing her health care provider for symptoms consistent with a UTI. The nurse understands that the most common route of infection is which of the following?
Watery with blood and mucus
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?
notify the physician about cloudy or foul-smelling urine
A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:
Painless hematuria
A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom?
severe abdominal pain with direct palpation or rebound tenderness
A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?
Monitor urine output hourly and report output less than 30 mL/hr.
A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care?
Intestinal malabsorption.
A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of:
Low-purine diet
A patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient?
Broiled chicken with low-fiber pasta
A patient with IBD would be encouraged to increase fluids, use vitamins and iron supplements, and follow a diet designed to reduce inflammation. Select the meal choice that would be recommended for a low-residue diet.
Absent
After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds?
Decreased pelvic muscle tone due to multiple pregnancies
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?
Physical and environmental conditions
An 82-year-old client experiences urinary incontinence. Which factor should the nurse assess before beginning a bladder training program for this client?
instructing the client to follow a 2- to 3-hour timed voiding schedule.
Bladder retraining following removal of an indwelling catheter begins with
Low residue
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?
high-fiber diet.
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes:
Low purine
Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?
Perform meticulous perineal care daily with soap and water
If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?
0.9% NS
Medical management of a patient with peritonitis includes fluid, electrolyte, and colloid replacement. The nurse knows to prepare the initial, most appropriate intravenous solution. Which of the following is the correct solution?
Relaxation of bladder wall
Sympathomimetics have which of the following effects on the body?
Usual pattern of elimination
The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?
The nursing assistant places the drainage bag on the client's abdomen for transport.
The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?
"My urine will be eliminated through a stoma."
The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?
Take the antibiotic for 3 days as prescribed.
The nurse is educating a female patient with a UTI on the pharmacologic regimen for treatment. What is important for the nurse to instruct the patient to do?
Anticholinergic
The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?
Hematuria
The nurse is obtaining a health history from a client describing urinary complications. Which assessment finding is most suggestive of a malignant tumor of the bladder?
Borborygmus
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition?
- Perform hand hygiene prior to patient care. - Provide careful perineal care. - Assist the patients with frequent toileting.
The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply.
Change in bowel habits
The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?
Dry skin thoroughly after washing
The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation?
administer an enema
The nurse working in the emergency department is caring for a client with signs and symptoms of appendicitis. Which order from the health care provider should the nurse question?
Change the wafer and pouch
The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention?
The clusters of ulcers take on a cobblestone appearance.
Which is a true statement regarding regional enteritis (Crohn's disease)?
Metabolic alkalosis
Vomiting results in which of the following acid-base imbalances?
Drink at least 8 to 10 large glasses of fluid every day
What information should the nurse include in the teaching plan for a client being treated for diverticulosis?
Pyuria
Which condition or laboratory result supports a diagnosis of pyelonephritis?
Bisacodyl
Which drug is considered a stimulant laxative?
Phenazopyridine
Which medication may be ordered to relieve discomfort associated with a urinary tract infection?
Hyperparathyroidism
Which metabolic defects are associated with stone formation?
- Risk for impaired skin integrity - Deficient knowledge: management of urinary diversion - Disturbed body image
Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply.
Excessive intake of vitamin D
Which of the following is a cause of a calcium renal stone?
Urinary tract
Which of the following is the most common site of a nosocomial infection?
Rectal bleeding
Which of the following is the most common symptom of a polyp?
Board-like abdomen
Which of the following would a nurse expect to assess in a client with peritonitis?
Urinary incontinence isn't a disease.
Which statement describing urinary incontinence in an older adult client is true?