Quiz 3

The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time?

1 hour

The nurse is assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve?

2 in.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial fibrillation

Which of the following is a term used to describe intestinal rumbling?

Borborygmus

The most common site for diverticulitis is the ileum.

False Rationale: The most common site for diverticulitis is not the ileum. The most common site for diverticulitis is the sigmoid.

Which is the most common motor dysfunction seen in clients diagnosed with stroke?

Hemiplegia

A patient diagnosed with IBS is advised to eat a diet that is:

High in fiber. A high-fiber diet is prescribed to control diarrhea and constipation and is recommended for patients with IBS.

Patients with irritable bowel disease (IBD) are at significantly increased risk for which of the following?

Osteoporosis Patients with IBD also have a significantly increased risk of osteoporotic fractures due to decreased bone mineral density. Patients are not at increased risk of deep vein thrombosis, hypotension, or pneumonia.

During assessment of a client for a malabsorption disorder, the nurse notes a history of abdominal pain and weight loss, marked steatorrhea, azotorrhea, and frequent glucose intolerance. Based on these clinical features, what diagnosis will the nurse suspect?

Pancreatic insufficiency

A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with:

paralytic ileus. Bowel sounds are hypoactive or absent in a client with a paralytic ileus. Clients with Crohn's disease and gastroenteritis have hyperactive bowel sounds because of increased intestinal motility. A complete bowel obstruction causes absent bowel sounds below the obstruction and hyperactive sounds above the obstruction.

What is the most common cause of small-bowel obstruction?

Adhesions Adhesions are scar tissue that forms as a result of inflammation and infection. Adhesions are the most common cause of small-bowel obstruction, followed by tumors, Crohn's disease, and hernias. Other causes include intussusception, volvulus, and paralytic ileus.

A client presents to the emergency room with a possible diagnosis of appendicitis. The health care provider asks the nurse to assess for tenderness at McBurney's point. The nurse knows to palpate which area?

Between the umbilicus and the anterior superior iliac spine Local tenderness in the right lower quadrant is elicited at McBurney's point when pressure is applied between the umbilicus and the anterior superior iliac spine.

Which drug is considered a stimulant laxative?

Bisacodyl

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?

"I'll have to wear an external collection pouch for the rest of my life." The client requires additional teaching if he states that he'll have to wear an external collection pouch for the rest of his life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection. Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily

A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem?

Bowel perforation Megacolon is a dilated and atonic colon caused by a fecal mass that obstructs the passage of colon contents. Symptoms include constipation, liquid fecal incontinence, and abdominal distention. Megacolon can lead to perforation of the bowel.

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.

Broiled chicken with low-fiber pasta A low-residue, high-protein, and high-calorie diet is recommended to reduce the size and number of stools. Foods to avoid include yogurt, fruit, salami, and peanut butter.

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?

Colonoscopy

Which statement provides accurate information regarding cancer of the colon and rectum?

Colorectal cancer is the third most common site of cancer in the United States.

A client is having a diagnostic workup for reports of frequent diarrhea, right lower abdominal pain, and weight loss. The nurse is reviewing the results of the barium study and notes the presence of "string sign." What does the nurse understand that this is significant of?

Crohn's disease The most conclusive diagnostic aid for Crohn's disease has classically been a barium study of the upper GI tract that shows a "string sign" on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.

A nurse practitioner is presenting health information about strokes at a clinic. She mentions that there are five categories of strokes based on their origin. Which of the following is the category that has the highest incidence of strokes (30%)?

Cryptogenic Cryptogenic strokes, which account for 30% of all strokes, refer to strokes that cannot be attributed to any specific cause.

A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?

Daily aspirin

The nurse is preparing a client for a test that involves inserting a thick barium paste into the rectum with radiographs taken as the client expels the barium. What test will the nurse prepare the client for?

Defecography

Which is one of the primary symptoms of irritable bowel syndrome (IBS)?

Diarrhea

A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing the therapeutic regimen. What would not be included?

Encourage the client to avoid exercise. Activity promotes healing and normal stool patterns. Proper cleansing prevents infection and irritation. Sitz baths promote healing, decrease skin irritation, and relieve rectal spasms. Encouragement promotes compliance with therapeutic regimen and prevents complications.

The nurse is caring for a patient who has malabsorption syndrome with an undetermined cause. What procedure will the nurse assist with that is the best diagnostic test for this illness?

Endoscopy with mucosal biopsy

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

Enterostomal nurse The surgeon should collaborate with the enterostomal nurse, who can address the client's concerns. The enterostomal nurse may schedule a visit with a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker aren't specialized in colostomy care, so they aren't the best choices for this situation.

What are expected patient outcomes for a patient recovering from a hemorrhagic stroke?

Exhibits absence of vasospasm Rationale: Expected patient outcomes for a patient recovering from a hemorrhagic stroke include absence of vasospasm, no seizures, normal speech patterns, and no visual changes

What is agnosia?

Failure to recognize familiar objects perceived by the senses Rationale: Agnosia is failure to recognize familiar objects perceived by the senses. Aphasia is an inability to express oneself or to understand language. Apraxia is an inability to perform previously learned purposeful motor acts on a voluntary basis. Ataxia is an impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance.

The nurse in an extended-care facility reports that a resident has clinical manifestations of fecal incontinence. The health care provider orders a diagnostic study to rule out inflammation. Which study will the nurse prepare the client for?

Flexible sigmoidoscopy

The nurse is caring for a patient who has had an appendectomy. What is the best position for the nurse to maintain the patient in after the surgery?

High Fowler's After surgery, the nurse places the patient in a high Fowler's position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Impaired Swallowing

When describing abdominal hernias to a group of nursing students, the instructor would identify which type as most common?

Inguinal The common abdominal hernias are inguinal, umbilical, femoral, and incisional, with inguinal hernias the most common type.

A patient with irritable bowel syndrome has been having more frequent symptoms lately and is not sure what lifestyle changes may have occurred. What suggestion can the nurse provide to identify a trigger for the symptoms?

Keep a 1- to 2-week symptom and food diary to identify food triggers. The nurse emphasizes and reinforces good dietary habits (e.g., avoidance of food triggers). A good way to identify problem foods is to keep a 1- to 2-week symptom and food diary.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding

The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?

Maintaining skin integrity

Which set of symptoms characterize Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations

What intervention would not be included in aspiration precautions for a patient in the acute phase of a stroke?

Raise HOB to 30 degrees when feeding Rationale: Interventions to prevent aspiration include a referral to speech therapy for swallowing evaluation; having the patient tuck the chin toward the chest when swallowing to close off the trachea, preventing aspiration into the lungs; providing thickened fluids or a pureed diet; and sitting the patient at a full upright position (90 degrees) when feeding or providing fluids. The patient's HOB should be elevated to 30 degrees at all times to prevent aspiration of secretions but would not prevent aspiration of food or fluids when feeding.

A nurse is caring for a client who had an ileal conduit 3 days earlier. The nurse examines the stoma site and determines that she should consult with the ostomy nurse. Which assessment finding indicates the need for further consultation?

Red, sensitive skin around the stoma site Red, sensitive skin around the stoma site may indicate an ill-fitting appliance beefy redness at a stoma site that isn't sensitive to touch is a normal assessment finding. Urine mixed with mucus is also a normal finding.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?

Restrict fluids before surgery.

A client presents to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated, causing the client to report pain in the RLQ. This positive sign is referred to as ________ and suggests the client may be experiencing ________.

Rovsing sign; acute appendicitis When an examiner deeply palpates the left lower abdominal quadrant and the client feels pain in the RLQ, this is referred to as a positive Rovsing sign and suggests acute appendicitis.

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke?

Spatial-perceptual deficits

The nurse is reviewing the laboratory test results of a client with Crohn disease. Which of the following would the nurse most likely find?

Stool cultures negative for microorganisms or parasite

A client is recently diagnosed with Crohn's disease and is beginning treatment. What first-line treatment does the nurse expect that the client will be placed on to decrease the inflammatory response?

Sulfasalazine

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?

The client exhibits signs of adequate GI perfusion.

Which is a true statement regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobblestone appearance. The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.

A client is being seen in the clinic for reports of painful hemorrhoids. The nurse assesses the client and observes the hemorrhoids are prolapsed but able to be placed back in the rectum manually. The nurse documents the hemorrhoids as what degree?

Third degree First degree hemorrhoids do not protrude. Second degree hemorrhoids prolapse outside the anal canal during defecation but reduce spontaneously. Third degree hemorrhoids prolapse to the extent that they require manual reduction. Fourth degree hemorrhoids prolapse to the extent that they may not be reduced.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?

Thrombolytic therapy has a time window of only 3 hours.

Fistulas are common in Crohn's disease.

True Rationale: Perianal involvement, fistulas, and abdominal mass are common in Crohn's disease.

Primary prevention is the best approach to avoiding hemorrhagic and ischemic stroke. true or false

True Rationale: Primary prevention is the best method to avoid hemorrhagic and ischemic stroke through management of modifiable risk factors including controlling hypertension, consuming alcohol in moderation, exercise, no smoking, and managing diabetes.

The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?

Usual pattern of elimination Constipation has many possible reasons and assessing the client's usual pattern of elimination is the first step in identifying the cause. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?

When symptoms cease, the client will return to presymptomatic state.

A client with a history of constipation is instructed to consume a high fiber diet. Which statement by the client about an appropriate food choice indicates the need for additional teaching?

White bread To achieve a high fiber diet, most daily grain choices should be whole grains, such as 100% whole wheat bread, whole wheat or bran cereal, oats, brown rice, or whole wheat pasta. White bread is not considered a whole grain source. Dried lentils are a vegetable protein that is low in fat and high in fiber; popcorn, like other seeds and nuts are good sources of fiber.

What is total nutrient admixture?

an admixture of lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals, and water Rationale: Parenteral nutrition is a method of supplying nutrients to the body by the intravenous route. Intravenous fat emulsion is an oil-in-water emulsion of oils, egg phospholipids, and glycerin. A central venous access device is designed and used for long-term administration of medications and fluids into central veins. Total nutrient admixture is lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals, and water.

A client has a 12-year history of cluster headaches. After the client describes the characteristics of the head pain, the nurse begins to discuss its potential causes. What would the nurse indicate that the origin of the headaches is:

unknown Although cluster headaches can be triggered by vasodilating agents, the cause of cluster headaches is unknown.