NURS 2207 GI Quiz
A client recovering from hepatitis A asks the nurse about returning to work. How would the nurse respond? 1. "As soon as you're feeling less tired, you may go back to work." 2. "Unfortunately, few people fully recover from hepatitis in less than 6 months." 3. "Gradually increase your activities because relapses may occur in those who return to full activity too soon." 4. "You cannot return to work for 6 months because the virus will still be in your stools, and you still are communicable."
3. "Gradually increase your activities because relapses may occur in those who return to full activity too soon." Rationale: Relapses are common; they occur after too early ambulation and too much physical activity. Fatigue is a cardinal symptom; if the client tires at rest, a return to work must be delayed. The client does not stay contagious for 6 months.
Which action is likely to reduce the pancreatic and gastric secretions of a client with pancreatitis? 1. Encourage clear liquids. 2. Obtain a prescription for morphine. 3. Assist the client into a semi-Fowler position. 4. Administer prescribed anticholinergic medication.
4. Administer prescribed anticholinergic medication. Rationale: Anticholinergic medications block the neural impulses that stimulate pancreatic and gastric secretions. Oral fluids stimulate pancreatic secretion. Morphine sulfate is an analgesic and does not decrease gastric secretions. The semi-Fowler position decreases pressure against the diaphragm to help relieve discomfort, but it does not decrease pancreatic secretions.
A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client appears to be angry and demanding. One day the unlicensed assistive personnel (UAP) tells the nurse, "I am very irritated with that client's constant demands. I'm not going in that room again." How would the nurse respond? 1. "The client is frightened. Let's think about the best approach we can take." 2. "You need to try to be patient with the client. He or she is going through a lot right now." 3. "I'll talk with the client. Maybe I can figure out the best way for us to handle this situation." 4. "Just ignore the client and get on with the rest of your work. Let someone else take a turn."
1. "The client is frightened. Let's think about the best approach we can take." Rationale: The response, "The client is frightened. Let's think about the best approach we can take" interprets the client's behavior without belittling the UAP's feelings; it encourages the UAP to get involved with plans for future care. Although the response, "You need to try to be patient with the client. He or she is going through a lot right now" recognizes the client's feelings, it would not help the UAP cope with the client. The response, "I'll talk with the client. Maybe I can figure out the best way for us to handle this" assumes the UAP has nothing to contribute and that only the nurse can deal with the problem. The response, "Just ignore the client and get on with the rest of your work. Let someone else take a turn" would not help the UAP, nor would it demonstrate an understanding of the client's feelings.
A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. Which would the nurse be prepared to administer to the client? 1. A low-residue diet 2. Intravenous therapy 3. Total parenteral nutrition 4. An oral electrolyte solution
2. Intravenous therapy Rationale: Intravenous therapy ensures a well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed via a low-residue diet. Total parenteral nutrition is not necessary at this point, although it may eventually be used. Oral electrolyte solution is not a well-controlled method to correct electrolyte deficiencies.
A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and intravenous (IV) fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? 1. Reduce gastric acidity 2. Reduce colonic irritation 3. Reduce intestinal absorption 4. Reduce bowel infection rate
2. Reduce colonic irritation Rationale: A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is followed to allow the bowel to rest, not to reduce infection rates.
A client with an obstruction of the pancreatic ducts is diagnosed with acute pancreatitis. A subtotal pancreatectomy is performed. The nurse would monitor the client for which postoperative complication? 1. Constipation 2. Cholecystitis 3. Paralytic ileus 4. Respiratory distress
3. Paralytic ileus Rationale: A paralytic ileus may occur because of the surgical manipulation of the gastrointestinal tract. If after pancreatic surgery the endocrine function of the pancreas is compromised, diarrhea and steatorrhea may develop because of insufficient pancreatic enzymes. Cholecystitis does not occur after a subtotal pancreatectomy; cholecystitis may accompany pancreatitis. Acute respiratory distress syndrome may occur 3 to 7 days after the onset of pancreatitis; it is related to pancreatitis, not subsequent to the surgery.
The nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? 1. Inclusion of transmural involvement of the small bowel wall 2. Higher occurrence of fistulas and abscesses from changes in the bowel wall 3. Pathology beginning proximally with intermittent plaques found along the colon 4. Involvement starting distally with rectal bleeding that spreads continuously up the colon
4. Involvement starting distally with rectal bleeding that spreads continuously up the colon Rationale: Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon; in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine. Intermittent areas of pathology occur in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall; therefore, abscesses and fistulas are rare. Abscesses and fistulas occur more frequently in Crohn disease.
The nurse gives a client with hepatitis A information about untoward signs and symptoms related to the disease. The nurse instructs the client to contact the primary health care provider if the client develops which symptom? 1. Fatigue 2. Anorexia 3. Yellow urine 4. Clay-colored stools
4. Clay-colored stools Rationale: Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the health care provider about fatigue and anorexia because these symptoms are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.
A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis would the nurse monitor in the client? 1. Crackles 2. Hypovolemia 3. Gastric reflux 4. Jugular vein distention
2. Hypovolemia Rationale: Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention. Crackles indicate an accumulation of fluid in the alveoli associated with hypervolemia, not hypovolemia. Gastric reflux occurs with gastroesophageal reflux disease (GERD), not with pancreatitis. Jugular vein distention indicates hypervolemia, not hypovolemia.
When assessing a client with Hepatitis A, the nurse is particularly careful with which substance to prevent transmission of the disease? 1. Urine 2. Saliva 3. Blood 4. Fecal matter
4. Fecal matter Rationale: The reservoir for Hepatitis A is fecal matter, so the nurse is particularly careful with any contact with fecal matter to prevent transmission of infection. Gonorrhea is contained in the genitourinary tract. Herpes is contained in saliva. Hepatitis B is contained in the blood.
Which autoantigens are responsible for the development of Crohn disease? 1. Crypt epithelial cells 2. Thyroid cell surface 3. Basement membranes of the lungs 4. Basement membranes of the glomeruli
1. Crypt epithelial cells Rationale: Crypt epithelial cells are considered the autoantigens responsible for Crohn disease. Thyroid cell surfaces are autoantigens responsible for Hashimoto thyroiditis. The pulmonary and glomerular basement membranes act as autoantigens responsible for Goodpasture syndrome.
The nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos would the nurse include in the teaching plan? 1. Hepatitis A 2. Hepatitis C 3. Hepatitis D 4. Hepatitis E
2. Hepatitis C Rationale: Hepatitis C is a blood-borne pathogen that can be transmitted via contaminated tattoo needles. Hepatitis A is not a blood-borne pathogen; it is spread through contaminated food or water. Although hepatitis D is a blood-borne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread through contaminated food or water.
The nurse reviews the laboratory results of a client with acute pancreatitis. Which test is significant in determining the client's response to treatment? 1. Platelet count 2. Amylase level 3. Red blood cell count 4. Erythrocyte sedimentation rate
2. Amylase level Rationale: In 90% of clients with acute pancreatitis, the amylase level is elevated up to three times above baseline; serum amylase usually returns to expected adult levels within 3 days after treatment begins. The platelet count is not an indicator of the response to treatment for pancreatitis; platelets are important in the control of bleeding. The red blood cell count is unchanged in acute pancreatitis, unless hemorrhage is present. The erythrocyte sedimentation rate is not an indicator of a response to treatment for pancreatitis.
In addition to hepatitis B, pneumococcal, Haemophilus influenzae type b, and varicella vaccines, which would the nurse expect a 20-month-old child who has been receiving immunizations on schedule to have had? 1. Two diphtheria, tetanus, acellular pertussis (DTaP), two inactivated polio vaccinations (IPVs), and one measles, mumps, rubella (MMR) 2. Four DTaPs, three IPVs, and one MMR 3. Three DTaPs, two IPVs, and two MMRs 4. Three DTaPs, three IPVs, and three MMRs
2. Four DTaPs, three IPVs, and one MMR Rationale: By 18 months of age a child should have received four DTaP vaccinations, three IPVs, and one MMR vaccination as well as hepatitis B, pneumococcal, Haemophilus influenzae type b, and varicella vaccines.
A client with an acute episode of ulcerative colitis is admitted to the hospital. When reviewing the client's laboratory results, the nurse identifies that the client's serum chloride level is decreased. Which method is the most efficient way to correct this problem? 1. Low-residue diet 2. Intravenous (IV) therapy 3. Oral electrolyte solution 4. Total parenteral nutrition (TPN)
2. Intravenous (IV) therapy Rationale: IV ensures a rapid, well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed. Oral electrolyte solution is not a rapid or well-controlled method for correcting electrolyte deficiencies. TPN is not necessary at this time, although it may be used eventually.
Which medication will the nurse question when it is prescribed for a client with acute pancreatitis? 1. Ranitidine 2. Cimetidine 3. Meperidine 4. Promethazine
3. Meperidine Rationale: Meperidine should be avoided because accumulation of its metabolites can cause central nervous system irritability and even tonic-clonic seizures (grand mal seizures). Ranitidine is useful in reducing gastric acid stimulation of pancreatic enzymes. Cimetidine is useful in reducing gastric acid stimulation of pancreatic enzymes. Promethazine is useful as an antiemetic for clients with pancreatitis.
Which statement by the client, recovering from an acute case of viral hepatitis, indicates understanding of the discharge instructions presented by the nurse? Select all that apply. One, some, or all responses may be correct. 1. "I will avoid alcohol because my liver is scarred and the alcohol causes more damage." 2. "I will eat four to seven small snacks or meals per day." 3 "I will take acetaminophen for pain rather than aspirin." 4 "I will eat foods high in carbohydrates, but moderate in fats and proteins." 5 "I will not have to use condoms during intercourse, because I have beaten this."
ANS: 1, 2, 4 Rationale: Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis. Clients should avoid alcohol, eat small frequent meals, and eat foods high in carbohydrates and moderate in fats and protein. The client needs to avoid unprotected sex because virus hepatitis is easily transmitted.
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Which would the nurse consider teaching about how gamma globulin provides passive immunity? 1. It increases production of short-lived antibodies. 2. It accelerates antigen-antibody union at the hepatic sites. 3. The lymphatic system is stimulated to produce antibodies. 4. The antigen is neutralized by the antibodies that it supplies.
4. The antigen is neutralized by the antibodies that it supplies. Rationale: Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.
A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and having experienced 10 liquid bowel movements in the past 24 hours. The nurse suspects that the client is dehydrated based on which assessment findings? Select all that apply. One, some, or all responses may be correct. 1. Moist skin 2. Sunken eyes 3. Decreased apical pulse 4. Dry mucous membranes 5. Increased blood pressure
ANS: 2, 4 Rationale: Sunken eyes and loss of skin turgor occur because of decreased intracellular and interstitial fluid associated with dehydration. Dry mucous membranes occur because of decreased intracellular and interstitial fluid associated with dehydration. The skin will be dry, not moist, with dehydration. The first sign of dehydration usually is tachycardia. The blood pressure will decrease, not increase, because of hypovolemia.
The nurse reviews the room assignments for clients who are scheduled for admission. One client is being hospitalized to receive intravenous steroids for management of Crohn disease. The nurse would question the assignment if the client is scheduled to have a roommate who has which illness? 1. Pancreatitis 2. Thrombophlebitis 3. Bacterial meningitis 4. Acute cholecystitis
3. Bacterial meningitis Rationale: The bacteria that cause meningitis are transmitted via air currents; the client with bacterial meningitis should be in a private room with airborne precautions to protect other people. Pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. Thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. Cholecystitis is not a communicable disease; it is inflammation of the gallbladder.
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication would the nurse assess the client after this surgery? 1. Infection caused by the excretion of feces 2. Injury caused by exposed intestinal mucosa 3. Altered bowel elimination caused by the ostomy 4. Limited water reabsorption caused by removal of intestine
4. Limited water reabsorption caused by removal of intestine Rationale: The continuous excretion of liquid feces may deplete the body of fluids and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-threatening complication. Although the stoma should be protected from injury and altered bowel elimination is a concern, these are not life-threatening complications.
The nurse is evaluating a client who has been receiving medical intervention for a diagnosis of Crohn disease. Which expected outcome is most important for this client? 1. Performs skin care 2. Tolerates oral fluids 3. Experiences less abdominal cramping 4. Gains a half pound (0.2 kilograms) per week
4. Gains a half pound (0.2 kilograms) per week Rationale: Weight loss usually is severe with Crohn disease; therefore, weight gain is a priority. This goal is specific, realistic, and measurable and has a time frame. Although skin care, tolerating oral fluids, and experiencing less abdominal cramping are important, they are not as high a priority as weight gain.
The nurse teaches a client who is concerned about hepatitis transmission routes. Which type of hepatitis spreads more frequently through food? 1. A 2. B 3. C 4. D
1. A Rationale: An RNA virus transmits hepatitis A, also known as an infectious hepatitis, via the fecal-oral route, most frequently though food. Hepatitis B transmission occurs parenterally, sexually, and by direct contact with infected body secretions. An RNA virus causes hepatitis C and is transmitted parenterally. Hepatitis D is a complication of hepatitis B.
A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F (38.3°C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, which clinical finding is a primary nursing concern for this client? 1. Acute pain 2. Inadequate nutrition 3. Electrolyte imbalance 4. Disturbed self-concept
1. Acute pain Rationale: Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation. Although clients with this medical diagnosis often are malnourished, addressing the client's pain takes priority. There are not enough data to determine electrolyte imbalance; additional data, such as for skin turgor, serum electrolytes, and intake and output, are needed to identify whether the client has a fluid and electrolyte imbalance. There are no data to support the presence of a disturbed self-concept.
A client who is obese and has a history of alcohol abuse is admitted to the hospital with a diagnosis of acute pancreatitis. Which is an appropriate initial client treatment goal? 1. Decreased pain 2. Selection of appropriate food choices 3. Joining Alcoholics Anonymous 4. A loss of 4 pounds (1.8 kg) per week
1. Decreased pain Rationale: Pain relief is the priority. Severe pain is associated with acute pancreatitis caused by inflammation of the pancreas, peritoneal irritation, and biliary tract obstruction. Selection of appropriate food choices, losing weight, and joining Alcoholics Anonymous are later goals.
A client is admitted to the hospital with a diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client? 1. Controlling constipation 2. Meeting nutritional needs 3. Preventing increased weakness 4. Anticipating a sexual alteration
2. Meeting nutritional needs Rationale: To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.
A client with severe Crohn disease develops a small bowel obstruction. Which clinical finding would the nurse expect the client to report? 1. Bloody vomitus 2. Projectile vomiting 3. Bleeding with defecation 4. Pain in the left lower quadrant
2. Projectile vomiting Rationale: Nausea and vomiting, accompanied by diffuse abdominal pain, commonly occur in clients with small bowel obstruction; the vomiting may be projectile and may contain bile or fecal material. Hematemesis is associated more closely with peptic ulcer disease. Bleeding with defecation is associated with hemorrhoids and anal fissures. Pain in the left lower quadrant is associated with diverticulitis. Pain associated with a small bowel obstruction usually is more diffuse.
A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to which major deficiency? 1. Ferrous sulfate 2. Protein 3. Ascorbic acid 4. Linoleic acid
2. Protein Rationale: Protein deficiency causes a low serum albumin level, which permits fluid shifts from the intravascular to the interstitial compartment, resulting in edema. Decreased protein also causes anemia; protein intake must be increased. Although a deficiency of ferrous sulfate will result in anemia, it will not cause the other adaptations. Ascorbic acid is unrelated to these adaptations. Linoleic acid is unrelated to these adaptations.
The nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is indicative of acute pancreatitis? 1. Blood glucose 2. Serum lipase 3. Serum bilirubin level 4. White blood cell count
2. Serum lipase Rationale: Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes such as cholecystitis. White blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes.
A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, which would the nurse expect to observe? 1. Melena 2. Steatorrhea 3. Hard, dry stool 4. Ribbon-shaped stool
2. Steatorrhea Rationale: Decreased secretion of lipase from the pancreas limits fat breakdown in the small intestine, resulting in increased fat content in feces; steatorrhea is soft, frothy, foul-smelling feces. Melena refers to black, tarry stool containing digested blood; melena is caused by upper gastrointestinal bleeding. Hard, dry stool reflects constipation; stools associated with pancreatitis are soft and frothy. Ribbon-shaped stool is associated with obstruction of the descending or sigmoid colon.
After many years of coping with ulcerative colitis, a client makes the decision to have a colectomy as advised by the primary health care provider. Which is most likely the significant factor that affected the client's decision? 1. It is temporary until the colon heals. 2. Surgical treatment cures ulcerative colitis. 3. Ulcerative colitis can progress to Crohn disease. 4. Without surgery, eating table foods is contraindicated.
2. Surgical treatment cures ulcerative colitis. Rationale: When the diseased bowel is removed, the client's symptoms cease. Surgical removal of a body part is not temporary, but permanent. Ulcerative colitis does not progress to Crohn disease; clients with ulcerative colitis have an increased risk for colorectal cancer. Without surgery, eating table foods is contraindicated is not a true statement; these clients can still eat table food.
The nurse is caring for a client who is positive for hepatitis A. Which precautions would the nurse take? 1. Wear a gown when entering the client's room. 2. Use gloves when removing the client's bedpan. 3. Clean eating utensils with bleach after use. 4. Wear a high-efficiency particulate air (HEPA) respirator when entering the client's room.
2. Use gloves when removing the client's bedpan. Rationale: The virus is present in the stool of clients with hepatitis A; therefore, standard precautions should be followed when handling excretions. The virus also may be present in urine and nasotracheal secretions. The Centers for Disease Control and Prevention (CDC; Canada: Public Health Agency of Canada [PHAC]) indicate that only standard precautions are necessary when caring for a client who is positive for the presence of hepatitis A. If a client is incontinent or using an incontinence device, the CDC (Canada: PHAC) recommends that contact precautions be implemented. Disposable utensils should be used and utensils discarded after use; the client's nasotracheal secretions contain the virus. Hepatitis A usually is not transmitted via the air. Airborne precautions, including use of the HEPA respirator, are not necessary.
A client with hepatitis A experiences anorexia, fatigue, and jaundice. The client's spouse and adult children living at home ask whether they should receive gamma globulin. Which response would the nurse make to the client's family? 1. "Gamma globulin is unnecessary, as long as you follow droplet precautions until the client is asymptomatic." 2. "Gamma globulin injections provide passive immunity for hepatitis B, not hepatitis A." 3. "You should call your primary health care provider immediately about obtaining gamma globulin injections." 4. "Your family member's type of hepatitis is no longer communicable, and gamma globulin is not required."
3. "You should call your primary health care provider immediately about obtaining gamma globulin injections." Rationale: Gamma globulin provides passive immunity to hepatitis type A, if administered to the household or sexual contacts within 2 weeks of exposure. Gamma globulin may provide some protection for those exposed to hepatitis A; contact, not droplet, precautions should be followed. Gamma globulin provides passive immunity for hepatitis type A, not type B. Gamma globulin provides some protection; the hepatitis type A virus is found in the stools of infected individuals before the onset of symptoms and during the first few days of illness.
A client is diagnosed with chronic pancreatitis. Which dietary instruction is important for the nurse to share with the client? 1. Eat a low-fat, low-protein diet. 2. Avoid foods high in carbohydrates. 3. Avoid ingesting alcoholic beverages. 4. Eat a bland diet with no snacks in between.
3. Avoid ingesting alcoholic beverages. Rationale: Alcohol will cause the most damage. It increases pancreatic secretions, which cause autodigestion of the pancreas, leading to severe pain. Although the diet should be low in fat, it should be high in protein; also, it should be moderate in carbohydrates. The client should consume a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet can be consumed, but snacks high in calories also are recommended.
Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis? 1. Turkey salad, French fries, sherbet 2. Cottage cheese, mixed fruit salad, milkshake 3. Salad, sliced chicken sandwich, gelatin dessert 4. Cheeseburger, tortilla chips, chocolate pudding
3. Salad, sliced chicken sandwich, gelatin dessert Rationale: The viral hepatitis diet should be high in carbohydrates, with moderate protein and fat content. A salad, chicken, and gelatin meal is the best choice. Turkey salad, French fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the hepatitis virus injures the intestinal mucosa and reduces the client's ability to metabolize lactose. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.
The parents of a child diagnosed with hepatitis A express concern that other family members may contract hepatitis because they only have one bathroom. Which response would the nurse reply? 1. "I suggest you buy an individual commode seat to use exclusively for your child's bathroom needs." 2. "Your child may use the bathroom, but you need to use disposable toilet seat covers." 3. "You will need to clean the bathroom from top to bottom every time a family member uses it." 4. "All family members, including your child, need to wash their hands after using the bathroom."
4. "All family members, including your child, need to wash their hands after using the bathroom." Rationale: Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper hand washing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. Cleaning the bathroom "from top to bottom" after each use is not feasible. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Hand washing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.
A client with hepatitis B asks the nurse, "Are there any medications to help me get rid of this problem?" Which is the best response by the nurse? 1. "Sedatives can be given to help you relax." 2. "We can give you immune serum globulin." 3. "Vitamin supplements are frequently helpful and hasten recovery." 4. "There are medications to help reduce viral load and liver inflammation."
4. "There are medications to help reduce viral load and liver inflammation." Rationale: Medications are available to help reduce the viral load (antivirals), including lamivudine, ribavirin, and adefovir dipivoxil. Although sedatives can be given to help the client relax, sedatives are given only as needed and do not treat the hepatitis. The response "We can give you immune serum globulin" would be used only during the incubation period. Vitamins are used as adjunctive therapy and will not eliminate the hepatitis.
*CLIENT CHART/EXHIBIT not included* A client is admitted to the hospital for acute pancreatitis. The nurse obtains the client's vital signs, performs a physical assessment, and reviews the client's health history. Which intervention is the priority? 1. Reduce environmental stimuli 2. Continue to monitor the vital signs. 3. Initiate constant observation. 4. Assess for alcohol withdrawal symptoms.
4. Assess for alcohol withdrawal symptoms. Rationale: Further assessment is indicated. Alcohol is a central nervous system depressant that will result in rebound agitation with increased temperature, pulse, respiratory rate, and blood pressure in the presence of acute abstinence. Additional signs/symptoms include tremulousness, agitation, lack of appetite, nausea, vomiting, insomnia, impaired cognition, and mild perceptual changes. Psychotic symptoms (i.e., hallucinations) may begin in 8 to 10 hours, and there are risks of unconsciousness, seizures, and delirium. The health care provider should be notified of the client's status. Reducing environmental stimuli is necessary because the client is in a neurologically irritable and hypermetabolic state. Initiating constant observation and monitoring vital signs are required because alcohol withdrawal can develop into a medical emergency.
A client is admitted to the hospital with gastrointestinal bleeding, and a nasogastric (NG) tube is inserted. Prescriptions include irrigating the tube with normal saline as needed to maintain patency. The nurse assesses the NG tube and determines that it is not patent. Which action would the nurse take? 1. Instill normal saline. 2. Assess breath sounds. 3. Auscultate for bowel sounds. 4. Check the tube for placement.
4. Check the tube for placement. Rationale: Checking the tube for placement reduces the risk of introducing the irrigant into the lungs. Instilling normal saline increases the risk of introducing irrigant into the lungs if the tube is not in the stomach. Assessing for breath sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. Auscultating for bowel sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant.
The nurse is assessing a client with Crohn disease who is scheduled for an upper gastrointestinal series. Which condition would necessitate the cancellation of the procedure? 1. Hemorrhoids 2. Hyperkalemia 3. Inflamed colon 4. Colon perforation
4. Colon perforation Rationale: When a client has a perforated viscera, barium can leak out of the intestinal tract and cause inflammation or an abscess. Although hemorrhoids may be irritating, they do not contraindicate barium studies. Serum potassium is unaffected; barium is insoluble and will not affect blood content. Barium studies are not contraindicated when the bowel is inflamed. An upper gastrointestinal series is useful in diagnosing ulcerative colitis and Crohn disease.
Which intervention would be included in the nursing plan of care to help a 10-year-old girl live with Crohn disease? 1. Recommending several rest periods throughout the day 2. Emphasizing that high-residue foods be included in the diet 3. Assuring her that when she reaches puberty she may discontinue her medication 4. Encouraging her to express feelings while focusing on the ways she is like her friends
4. Encouraging her to express feelings while focusing on the ways she is like her friends Rationale: Focusing on feelings and abilities promotes effective coping and increases self-esteem. Children do not like to be different from their friends. The child will self-limit activity during an exacerbation; at other times the child should not need any more rest than her healthy peers. High-roughage foods are limited because they can trigger intestinal inflammation. Telling the child that she may discontinue the medication once she reaches puberty is false reassurance; there is no time limit as to when or if medications can be discontinued.
A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides which benefit? 1. Is the easiest method for administering needed nutrition 2. Is the safest method for meeting the client's nutritional requirements 3. Will satisfy the client's hunger without the discomfort associated with eating 4. Will meet the client's nutritional needs without causing the discomfort precipitated by eating
4. Will meet the client's nutritional needs without causing the discomfort precipitated by eating Rationale: Providing nutrients by the intravenous route eliminates pancreatic stimulation, reducing the pain experienced with pancreatitis. TPN is used to meet the client's needs, not the nurse's needs. TPN creates many safety risks for the client. Hunger can be experienced with TPN therapy.
Parenteral vitamins are prescribed for the client with Crohn disease. The client asks why the vitamins have to be given intravenously (IV) rather than by mouth. Which rationales will the nurse provide? Select all that apply. One, some, or all responses may be correct. 1. "They provide more rapid action results." 2. "They decrease colon irritability." 3. "Oral vitamins are less effective." 4. "Intestinal absorption may be inadequate." 5. "Allergic responses are less likely to occur."
ANS: 1, 3, 4 Rationale: Absorption through the gastrointestinal (GI) tract is impaired, and parenteral administration goes directly into the intravascular compartment. Disease of the GI tract hampers absorption. Because the mucosa of the intestinal tract is damaged, its ability to absorb vitamins taken orally is greatly impaired. IV vitamins do not decrease colonic irritability. Route of administration does not affect allergic response.
The nurse is eliciting a health history from a client with ulcerative colitis. Which factor would the nurse consider to be most likely associated with the client's colitis? 1. Food allergy 2. Infectious agent 3. Dietary components 4. Genetic predisposition
4. Genetic predisposition Rationale: Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease, are familial, which suggests that they are hereditary. Although food allergy or an infectious agent may be causative factors, they are not the most common factors. No specific dietary component has been identified.
Which reported clinical manifestations would the nurse expect from a client with ulcerative colitis? Select all that apply. One, some, or all responses may be correct. 1. Fever 2. Diarrhea 3. Gain in weight 4. Spitting up blood 5. Abdominal cramps
ANS: 1, 2, 5 Rationale: The inflammatory process can promote a fever and tends to increase peristalsis, causing intestinal spasms and diarrhea. As ulceration occurs, the loss of blood leads to anemia. The client will lose weight (not gain it) because of anorexia and malabsorption. Hemoptysis (coughing up blood from the respiratory tract) is not a related sign.
Which type(s) of hepatitis most commonly spread by consuming contaminated food and water, or by fecal contamination? Select all that apply. One, some, or all responses may be correct. 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D 5. Hepatitis E
ANS: 1, 5 Rationale: Hepatitis A and E most commonly are spread through the fecal-oral route. Hepatitis B most commonly is spread through the sharing of needles and through unprotected sex. Hepatitis C and D most commonly are spread through intravenous (IV) drug needle sharing.
A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. How would the nurse respond? 1. "They stimulate prothrombin production." 2. "They aid in the absorption of fat-soluble vitamins." 3. "They promote bilirubin secretion in the urine." 4. "They help the common bile duct contract stronger."
2. "They aid in the absorption of fat-soluble vitamins." Rationale: Bile salts are used to aid digestion of fats and absorption of the fat-soluble vitamins A, D, E, and K. Bile salts are not involved in stimulating prothrombin production, in promoting bilirubin secretion in the urine, or in stimulating contraction of the common bile duct.
A client with the diagnosis of Crohn disease tells the nurse, "My partner dates other people. I believe that behavior has caused an increase in my symptoms." Which is an appropriate initial nursing response? 1. Help the client explore personal attitudes. 2. Educate the partner about the illness and events that affect the client's symptoms. 3. Suggest the client should not date the partner to determine if symptoms change. 4. Schedule the client and the partner for a counseling session.
1. Help the client explore personal attitudes. Rationale: Because emotional stress can influence the progress of Crohn disease, initially the nurse should help the client explore self-attitudes to aid in better understanding the feelings engendered by the partner dating others. Initially, the nurse should help the client explore the situation and the feelings it engenders rather than involve the partner. The client should make the decision about continuing to date the partner. Scheduling the client and the partner for a counseling session is premature; the client is not ready for a joint counseling session.
The nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included in the diet. Which food choices indicate that the teaching by the nurse is effective? Select all that apply. One, some, or all responses may be correct. 1. Orange juice 2. Creamed soup 3. Jelly sandwich 4. Lean roast beef 5. Scrambled eggs
ANS: 3, 4, 5 Rationale: A jelly sandwich is low in residue and is less irritating to the colon than other foods. Lean roast beef is low in residue and is less irritating to the colon than other foods. Eggs are low in residue and are less irritating to the colon than other foods. Orange juice contains cellulose (fiber), which is not absorbed and irritates the colon. Milk in creamed soup contains lactose, which is irritating to the colon.
The hepatitis B-positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. Which is the proper dosage of this vaccine? 1.) 1.0 mL subcutaneously before discharge 2.) 0.5 mL subcutaneously within 24 hours of birth 3.) 1.0 mL intramuscularly within 24 hours of birth 4.) 0.5 mL intramuscularly within 12 hours of birth
4.) 0.5 mL intramuscularly within 12 hours of birth Rationale: HBIG must be given within 12 hours of birth to be effective. The correct dose is 0.5 mL, and it must be given intramuscularly. The vaccine is not given subcutaneously.
Which types of hepatitis develop into a chronic form of the disease? Select all that apply. One, some, or all responses may be correct. 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D 5. Hepatitis E
ANS: 2, 3, 4 Rationale: Hepatitis B and C generally develop into chronic hepatitis. Hepatitis D is an incomplete virus that can become chronic and is dependent on the presence of hepatitis B to survive. Hepatitis A and E are acute, self-limiting infections that resolve over time and do not develop into chronic hepatitis.
Which type of hepatitis virus spreads through contaminated food and water? 1. Hepatitis A virus 2. Hepatitis B virus 3. Hepatitis C virus 4. Hepatitis D virus
1. Hepatitis A virus Rationale: Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.
A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. For which potential life-threatening complication would the nurse assess the client postoperatively? 1.Wound infection 2. Ischemia of the stoma 3. Fluid deficit and electrolyte imbalance 4. Excoriation of skin around the stoma
3. Fluid deficit and electrolyte imbalance Rationale: An ileostomy directs liquid feces out of the body, bypassing the large intestine, where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although a wound infection is always a possibility after surgery, it is unlikely and not life threatening. Although the stoma should be assessed to ensure that it is not dark, but pink and moist indicating adequate circulation, this complication is unlikely and not life threatening. Although impaired skin integrity can occur when liquid feces remain on the skin surrounding the stoma, this should not occur if an appliance to collect the discharge is used correctly. Also, impaired skin integrity is not a life-threatening complication.
Corticosteroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client identifies which times for the medication schedule? 1. At bedtime with a snack 2. Three times a day with meals 3. In the early morning with food 4. One hour before or 2 hours after eating
3. In the early morning with food Rationale: Taking the medication in the early morning mimics usual adrenal secretions; food helps reduce gastric irritation. Diurnal rhythms may be altered, and steroids are ulcerogenic; they should be taken with more than just a snack. Steroids cause gastric irritation and should be taken with food. Although food helps decrease gastric irritation, dividing the dose and taking it throughout the day may alter regular diurnal rhythms; it should be taken in the early morning with food.
Which statement indicates the patient understands the origin of hepatitis C? 1. "You can catch it while you're getting a tattoo." 2. "You're more likely to get it in crowded living conditions." 3. "The disease is passed from person to person by casual contact." 4. "People working at restaurants can give it to you if they don't wash their hands."
1. "You can catch it while you're getting a tattoo." Rationale: The hepatitis C virus (HCV) is a blood-borne pathogen; it can be acquired during the application of a tattoo with equipment that is contaminated with the hepatitis C virus. Hepatitis C is not transmitted by close contact in crowded spaces; HCV is a blood-borne pathogen. HCV is not transmitted by casual contact; it is a blood-borne pathogen. The fecal-oral route of transmission is associated with hepatitis A, not hepatitis C.
A child is born to a mother whose hepatitis B status is negative. While assessing the newborn, the nurse finds that the birth weight is 1.8 kg. Which action is appropriate in this situation? 1. Administer HepB vaccine to the newborn 1 month after birth. 2. Administer monovalent HepB vaccine to the newborn during discharge. 3. Administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. 4. Administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth.
1. Administer HepB vaccine to the newborn 1 month after birth. Rationale: The immune response to the HepB vaccine is not optimum in newborns who weigh less than 2 kg. Because the mother's hepatitis B status is negative, the first dose of HepB vaccine should be administered 1 month after birth. There is no need to administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth, because the mother's hepatitis B status is negative. Monovalent HepB vaccine is administered during discharge to newborns whose birth weight is more than 2 kg. If the infant were born to a hepatitis B-positive mother, HepB vaccine and 0.5 mL of HBIG would be administered within 12 hours of birth.
The nurse is performing a physical assessment of a client with ulcerative colitis. Which symptom is often associated with a serious complication of this disorder? 1. Decreased bowel sounds 2. Loose, blood-tinged stools 3. Distention of the abdomen 4. Intense abdominal discomfort
1. Decreased bowel sounds Rationale: Decreased intestinal motility is associated with serious problems, such as perforation or toxic megacolon. Loose, blood-tinged stools are an uncomfortable but less serious manifestation. Distention of the abdomen is an expected response that is not of primary concern at this time. Intense pain is a symptom of ulcerative colitis, not a complication.
While awaiting surgery, a client with a history of Crohn disease is receiving total parenteral nutrition (TPN) on an outpatient basis. The nurse teaches the client that TPN helps prepare for surgery by which process? 1. Decreasing fecal bulk 2. Preventing bowel infection 3. Providing stimulation of secretions 4. Maintaining negative nitrogen balance
1. Decreasing fecal bulk Rationale: By decreasing fecal bulk and bowel stimulation, TPN provides rest for the bowel while the client awaits surgery. TPN does not prevent a bowel infection. TPN does not stimulate gastrointestinal secretions. TPN promotes positive nitrogen balance.
A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The client states, "I am now ready for the surgery to create an ileostomy." Which nursing intervention best meets the client's needs at this time? 1. Parenterally replace the client's fluids and electrolytes. 2. Adjust client's diet to promote weight gain. 3. Provide anticipatory teaching on the use of ileostomy appliances. 4. Encourage client interaction with other clients who have an ileostomy.
1. Parenterally replace the client's fluids and electrolytes. Rationale: When a client has an ulcerative colitis exacerbation, the client may have more than 10 stools per day, and the stools are bloody and full of mucus. The client can become dehydrated and lose vital electrolytes. Parenterally replacing fluids and electrolytes is a life-saving strategy; replacement occurs before performing the surgery to stabilize the client. Helping the client regain former body weight is not the priority at this time. The client is neither physically nor cognitively ready to learn the psychomotor skill of how to manage an ileostomy. The client is not demonstrating a readiness for contact with other persons with ileostomies at this time.
A client is diagnosed as having the hepatitis B virus (HBV). The nurse reviews the client's health history for situations in which exposure may have occurred. Which event does the nurse determine is most likely the source of this infection? 1. The client received a small tattoo on the arm 3 months ago. 2. The client assisted in the emergency birth of a baby 2 weeks ago. 3. The client worked for a month in an undeveloped area in a foreign country 4 months ago. 4. The client attended an ecological conference in a large urban center 2 months ago.
1. The client received a small tattoo on the arm 3 months ago. Rationale: Any situation in which a needle is inserted under the skin is a potential source of hepatitis; according to the Centers for Disease Control and Prevention, the range of the incubation period is 45 to 180 days; however, the average incubation period is 60 to 90 days. Hepatitis B is not transmitted via inadequate sanitation or a contaminated water supply. Hepatitis B is not transmitted by casual proximity to others.
A client is hospitalized with acute pancreatitis. Which would be included in the client's plan of care? 1. Use intravenous (IV) fluids. 2. Season foods sparingly. 3. Eat small meals frequently. 4. Limit coffee to three cups per day.
1. Use intravenous (IV) fluids. Rationale: Acute pancreatitis requires an NPO (nothing by mouth) status to allow the pancreas to rest. IV fluids are administered. Spicy, seasoned foods stimulate the pancreas and should be avoided, not just sparingly used. Small, frequent feedings place less demand on the pancreas to release digestive enzymes and are instituted when the acute phase is resolved. Fats stimulate the release of lipase from the pancreas, whether they are saturated or unsaturated fats, and should be avoided. Coffee stimulates pancreatic secretions and should be avoided.
Which nursing intervention would prevent stimulation of the pancreas in a client with acute pancreatitis? 1. Maintain the gastric pH at a level of less than 3.5. 2. Encourage the resumption of activities of daily living. 3. Administer the histamine H2-receptor antagonist as prescribed. 4. Ensure that the nasogastric tube remains in the fundus of the stomach.
3. Administer the histamine H2-receptor antagonist as prescribed. Rationale: The histamine H2-receptor antagonist medication inhibits histamine at H2-receptor sites in parietal cells, thus decreasing gastric secretion and preventing pancreatic stimulation. A lower pH will stimulate pancreatic secretion, which contains bicarbonate ions that neutralize the acid. The client should rest to decrease stimulation of the pancreas. The tube should be positioned nearer the pylorus for the removal of gastric contents.
Which nursing interventions are required for hepatitis A? 1. Private room with the door closed 2. Gown, mask, and gloves for all persons entering the room 3. Gown and gloves when handling articles contaminated by urine or feces 4. Gowns and gloves only when handling the client's soiled linen, dishes, or utensils
3. Gown and gloves when handling articles contaminated by urine or feces Rationale: Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.
A client with ulcerative colitis has experienced frequent severe exacerbations over the past several years. The client is admitted to the hospital with intense pain, severe diarrhea, and cachexia. Which therapeutic course would the nurse expect the primary health care provider to explore with this client? 1. Intensive psychotherapy 2. Continued medical therapy 3. Surgical therapy (colectomy) 4. Diet therapy (low-residue, high-protein diet)
3. Surgical therapy (colectomy) Rationale: If medical management fails, surgical therapy is the next logical choice because it removes the affected intestine. Psychotherapy might improve the client's ability to cope with the disease, but it will not solve the physical problems. Continued medical therapy and diet therapy are classic interventions that probably have been tried during prior exacerbations and have failed.
Discharge planning for a client with chronic pancreatitis includes dietary education. Which client statement indicates to the nurse that further teaching is needed? 1. "I must eat foods high in calories." 2. "I should avoid alcoholic beverages." 3. "I will eat more often but in smaller amounts." 4. "I can eat foods high in fat now that the acute stage is over."
4. "I can eat foods high in fat now that the acute stage is over." Rationale: The nurse needs to follow up on the client statement that indicates eating foods high in fat can be allowed. A low-fat diet should be followed to avoid diarrhea. All the rest of the client responses are correct and do not require additional teaching. The response to eating foods high in calories is appropriate because additional calories are needed to maintain weight. The response to avoiding alcoholic beverages is appropriate to prevent overstimulation of the pancreas. Small, frequent meals limit stimulation of the pancreas and are appropriate.
The parent of a newborn asks the nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. Which response would the nurse provide? 1. "A newborn's spleen can't produce efficient antibodies." 2. "Infants younger than 2 months are rarely exposed to infectious disease." 3. "The immunization will attack the infant's immature immune system and cause the disease." 4. "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."
4. "Maternal antibodies interfere with the development of active antibodies by the infant when immunized." Rationale: Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases. The spleen does not produce antibodies. Young infants often are exposed to infectious diseases. The viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease.
The nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "How does my drinking relate to my diagnosis?" Which effect of alcohol would the nurse include when responding? 1. It promotes the formation of calculi in the cystic duct. 2. It stimulates the pancreas to secrete more insulin than it can immediately produce. 3. It alters the composition of enzymes so they are capable of damaging the pancreas. 4. It increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas.
4. It increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas. Rationale: Alcohol stimulates pancreatic enzyme secretion and an increase in pressure in the pancreatic duct. The backflow of enzymes into the pancreatic interstitial spaces results in partial digestion and inflammation of the pancreatic tissue. Although blockage of the bile duct with calculi may precipitate pancreatitis, this is not associated with alcohol. Alcohol does not deplete insulin stores; the demand for insulin is unrelated to pancreatitis. Although the volume of secretions increases, the composition remains unchanged.
A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which condition results from this imbalance? 1. Hemorrhage with subsequent anemia 2. Diminished resistance to bacterial insult 3. Malnutrition of cells, especially hepatic cells 4. Reduction of colloidal osmotic pressure in the blood
4. Reduction of colloidal osmotic pressure in the blood Rationale: Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.
A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information would the nurse include in a response to this question? 1. Malignant growth 2. Pocket of undigested food particles 3. Sac filled with pus from necrotic pancreatic tissue 4. Walled-off space of pancreatic enzymes and exudate
4. Walled-off space of pancreatic enzymes and exudate Rationale: A pseudocyst of the pancreas is a walled-off space that contains fluid, pancreatic enzymes, tissue debris, and inflammatory exudate. A malignant growth is cancer. A pseudocyst is not a pocket of undigested food particles. A pancreatic abscess is a sac filled with pus from necrotic pancreatic tissue.
The nurse provides education for a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions would be included in the teaching plan? Select all that apply. One, some, or all responses may be correct. 1. Preventing constipation 2. Screening of blood donors 3. Avoiding shellfish in the diet 4. Limiting hepatotoxic medication therapy 5. Maintaining a monogamous sexual relationship
ANS: 2, 5 Rationale: Contracting hepatitis B through blood transfusions can be prevented by screening donors and testing the blood. Hepatitis B can be transmitted via contaminated body fluids such as semen, saliva, and urine. Having multiple sexual partners increases the risk. A monogamous sexual relationship with an infection-free individual eliminates the risk. Preventing constipation is not related to limiting the risk for contracting hepatitis B. Avoiding shellfish in the diet limits the risk for contracting hepatitis A. Limiting hepatotoxic medication therapy does not prevent transmission of hepatitis B.
The nurse is teaching a client with an acute exacerbation of ulcerative colitis about an appropriate diet. Which food selected by the client indicates that the dietary teaching is effective? 1. Orange juice 2. Scrambled eggs 3. Vanilla milkshake 4. Creamed potato soup
2. Scrambled eggs Rationale: Low-fiber and lactose-free foods are recommended during acute exacerbations. Eggs are low-residue and less irritating to the colon than the other foods. Orange juice is high in fiber and contains cellulose, which is not absorbed and irritates the colon. Milk, found in the vanilla milkshake and creamed potato soup, contains lactose, which is irritating to the colon.
A client is admitted with the diagnosis of acute pancreatitis. Which clinical manifestations would the nurse assess in the client? Select all that apply. One, some, or all responses may be correct. 1. Jaundice 2. Acute pain 3. Hypertension 4. Hypoglycemia 5. Increased amylase
ANS: 1, 2, 5 Rationale: Obstruction of the common bile duct by inflammation leads to jaundice. Autodigestion of the pancreas causes severe abdominal pain. Obstruction of the pancreatic duct leads to elevated levels of amylase and lipase. Hypotension, not hypertension, is caused by fluid shifting out of the intravascular space. Decreased pancreatic function causes hyperglycemia, not hypoglycemia.
The nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes which statement? 1. "I should wash my hands frequently." 2. "I should launder my clothes separately." 3. "I should put used tissues in the garbage." 4. "I should wear a mask when leaving the house."
1. "I should wash my hands frequently." Rationale: Hepatitis A microorganisms are transmitted via the anal-oral route; hand washing, particularly after toileting, is the most important precaution. The response "I should launder my clothes separately" will not deter the spread of the virus; hand washing is necessary. Putting used tissue in the garbage is important, but hand washing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.
Which immunization protocol would the nurse follow when administering a hepatitis B vaccine to an infant whose mother is diagnosed HBsAg-positive during pregnancy? 1. Hepatitis B immune globulin 0.5 mL is given along with the first dose of Hepatitis B vaccine. 2. Hepatitis B immune globulin is given within a week after obtaining the mother's laboratory reports. 3. Hepatitis B immune globulin is not administered because the first dose of Hepatitis B vaccine itself is sufficient. 4. Hepatitis B immune globulin is not administered; however, the second dose of the hepatitis B vaccine is given after 1 month.
1. Hepatitis B immune globulin 0.5 mL is given along with the first dose of Hepatitis B vaccine. Rationale: The immunization protocol recommended for an infant born to a mother who is HBsAg-positive would be to administer 5 mcg of Hepatitis B vaccine within 12 hours of birth along with 0.5 mL of hepatitis B immune globulin (HBIG) at the same time but at a different site. This HBIG provides the infant immediate protection against HBsAg acquired from the mother. In cases of infants born to mothers whose HBsAg status is unknown at the time of birth, the immunization protocol is decided based on laboratory reports obtained after analyzing the maternal blood sample. If the reports suggest that the mother is HBsAg-positive, HBIG should be administered within 1 week. In cases of infants born to mothers who are HBsAg-negative, the first dose of 5-mcg Hepatitis B vaccine administered within 12 hours of birth is sufficient. Generally, this is followed by a second dose after 1 month and a third dose 6 months after administering the first dose.
A client receiving the medication buspirone is admitted to the hospital with a diagnosis of possible hepatitis. Which action will the nurse take? 1. Withhold the medication. 2. Give the buspirone with milk. 3. Reduce the dosage of the medication. 4. Ensure that the medication can be given parenterally.
1. Withhold the medication. Rationale: The medication should be held because hepatitis prolongs elimination of the medication and may result in toxic accumulation. Milk does not change the effect of the medication. The medication must be stopped, not reduced. The medication is available only in an oral form; in addition, the route of administration will not influence the occurrence of toxic accumulation.
A client is diagnosed with hepatitis A. The nurse takes the client's history. Which employment history is most likely linked to the development of hepatitis A? 1. Works at a plumbing business 2. Works in a hemodialysis unit at a hospital 3. Works as a dishwasher at a local restaurant 4. Works at an occupational arsenic compound business
1. Works at a plumbing business Rationale: Hepatitis A primarily is spread via a fecal-oral route; sewage-polluted water may harbor the virus. Working at a hemodialysis unit is closely linked to hepatitis types B, C, and D; these types are more often spread via the blood-borne route. Using disposable equipment and proper handling of syringes decreases the risk of spreading the virus. Working as a dishwasher at a local restaurant does not increase the risk of developing the disease, but it will increase the risk of an infected individual spreading the disease to others. Exposure to arsenic or carbon tetrachloride will not cause hepatitis A.
A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change? 1. Stimulation of the liver to produce an excess quantity of bile pigments 2. Inability of the liver to remove normal amounts of bilirubin from the blood 3. Increased destruction of red blood cells during the acute phase of the disease 4. Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
2. Inability of the liver to remove normal amounts of bilirubin from the blood Rationale: Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera. With hepatitis, the liver does not secrete excess bile. Destruction of red blood cells does not increase in hepatitis. Decreased prothrombin levels cause spontaneous bleeding, not jaundice.
A client is hospitalized with a diagnosis of acute pancreatitis. The plan of care is focused on the goals of maintaining nutrition, promoting rest, maintaining fluids and electrolytes, and decreasing anxiety. Which interventions would the nurse implement? Select all that apply. One, some, or all responses may be correct. 1. Provide a low-fat diet 2. Administer analgesics 3. Teach relaxation exercises 4. Encourage walking in the hall 5. Monitor cardiac rate and rhythm 6. Observe for signs of hypercalcemia
ANS: 2, 3, 5 Rationale: Analgesics, histamine-receptor antagonists, and proton pump inhibitors may be administered to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Relaxation will decrease the metabolic rate, which will decrease gastrointestinal activity, including the secretion of pancreatic enzymes. Monitoring cardiac rate and rhythm is necessary to assess for hypokalemia and fluid volume changes. The client would be kept nothing by mouth to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Walking increases the metabolic rate, which will increase gastrointestinal activity, including the secretion of pancreatic enzymes. Hypocalcemia, not hypercalcemia, occurs because of calcium and fatty acids combining during fat necrosis.
