chapter 39 - prepu
A C E
A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. A. Diarrhea B. Hypertension C. Diaphoresis D. Decreased bowel sounds E. Tachycardia
B
A nurse is performing an assessment for a client who presents to the clinic with an erythemic, fissuring lip lesion with white hyperkeratosis. What does the nurse suspect that these findings are characteristic of? A. Sialadenitis B. Actinic cheilitis C. Frey syndrome D. Human papillomavirus lesion
A
A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate? A. Achalasia B. Diffuse spasm C. Hiatal hernia D. Gastrosophageal reflex disease
D
A client has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the client's care? A. Risk for Decreased Cardiac Output Related to Vasovagal Response B. Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption C. Risk for Impaired Verbal Communication Related to Oral Trauma D. Risk for Aspiration Related to Inhalation of Gastric Contents
C
A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document? A. Erythroplakia B. Aphthous stomatitis C. Hairy leukoplakia D. Nicotine stomatitis
B
A nurse inspects the Stensen duct of the parotid gland to determine inflammation and possible obstruction. What area in the oral cavity would the nurse examine? A. Roof of the mouth next to the incisors B. Buccal mucosa next to the upper molars C. Dorsum of the tongue D. Posterior segment of the tongue near the uvula
A
The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse? A. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. B. Remove the aspirated fluid and do not reinstill. C. Discontinue the infusion. D. Dilute the gastric tube feeding solution with water and continue the feeding.
B
The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition? A. Periapical abscess B. Boerhaave syndrome C. Zenker diverticulum D. Halitosis
B
The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? A. Administer the feeding by bolus to prevent continuous intestinal distention. B. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. C. Administer the feeding at a warm temperature to decrease peristalsis. D. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration.
B D E
Which of the following is a proton pump inhibitor used in the treatment of gastrosophageal reflux disease (GERD)? Select all that apply. A. Famotidine (Pepcid) B. Rabeprazole (AcipHex) C. Nizatidine (Axid) D. Esomeprazole (Nexium) E. Lansoprazole (Prevacid)
D
Which of the following is the most common type of diverticulum? A. Intramural B. Epiphrenic C. Mid-esophageal D. Zenker's diverticulum