Exam 2 NUR 306 Prep U
A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching? "How did this happen? I've been faithful my entire marriage." "I'll be very careful when preparing food for my family." "I'll wash my hands often." "I'll take all my medications as ordered."
"How did this happen? I've been faithful my entire marriage." The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications
The nurse is assessing a client admitted with suspected pancreatitis. Which question will the nurse prioritize when assessing this client? "How many meals do you eat every day?" "How much alcohol do you consume in a day?" "When was the last time you took acetaminophen?" "How often and how long do you exercise each day?
"How much alcohol do you consume in a day?"
A client with obesity is suspected of having nonalcoholic fatty liver disease. Which diagnostic labs does the nurse anticipate the client needing? Select all that apply. Glycosylated hemoglobin Fasting glucose Aspartate aminotransferase Alanine aminotransferase Triglycerides
Aspartate aminotransferase Alanine aminotransferase Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are two liver function tests that will be used in diagnosing nonalcoholic fatty liver disease, a complication of obesity. Triglycerides, glycosylated hemoglobin (HbgA1C), and fasting glucose are diagnostic tests; however, these are not generally required in diagnosing nonalcoholic fatty liver disease.
A nurse prepares nutrition education for a client who will undergo bariatric surgery. What nutrition suggestion best indicates a beneficial effect on the number and quality of bowel movements the client may have after surgery? Increase fluid intake Avoid high-fat foods Eat a wide variety of foods Increase protein intake
Avoid high-fat foods Reducing the amount of fat will have a direct beneficial effect on the number and quality of bowel movements a client may have. Increasing fluid intake will help, but it is not the most beneficial. The client should not be encouraged to eat a wide variety of foods; rather, instruction on foods that will be best tolerated will be encouraged. Protein intake does not have a direct correlation to the client's quality of bowel movements post-bariatric surgery.
The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse? Inform the patient that it will only last a minute and continue with the procedure. Clamp the tubing and give the patient a rest period. Stop the irrigation and remove the tube. Replace the fluid with cooler water since it is probably too warm.
Clamp the tubing and give the patient a rest period. When irrigating a colostomy, the nurse should allow tepid fluid to enter the colon slowly. If cramping occurs, the nurse should clamp off the tubing and allow the patient to rest before progressing. Water should flow in over a 5- to 10-minute period.
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? Peptic ulcer disease Esophageal cancer Gastroesophageal reflux disease Diverticulitis
Gastroesophageal reflux disease Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis
A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction? Gray Black Red Green
Gray A gray-white stool color is common with a biliary obstruction because the stool is no longer colored with bile pigments.
The nurse visits the home of a client recovering from acute gastritis. Which observation indicates that teaching about the disorder was effective? Medications placed in a pillbox Extinguished cigarettes in an ashtray Tomato sauce simmering on the stove Cup of caffeinated coffee on the kitchen table
Medications placed in a pillbox The client with acute gastritis should be instructed on methods of keeping track of medications such as placing the doses into a pillbox. The client should also be instructed about foods and substances that may cause gastritis, including nicotine, spicy seasoned foods, and caffeine. Cigarettes in the ashtray, tomato sauce, and caffeinated coffee indicate that additional teaching is required.
Which is a true statement regarding gastric cancer? Most clients are asymptomatic during the early stage of the disease. Women have a higher incidence of gastric cancer. The prognosis for gastric cancer is good. Most cases are discovered before metastasis.
Most clients are asymptomatic during the early stage of the disease. Most clients are asymptomatic during the early stage of the disease. Men have a higher incidence of gastric cancer. The prognosis is poor because the diagnosis is usually made late because most clients are asymptomatic during the early stage. Most cases of gastric cancer are discovered only after local invasion has advanced or metastases are present.
When caring for a client with acute pancreatitis, the nurse should use which comfort measure? Administering an analgesic once per shift, as ordered, to prevent drug addiction Positioning the client on the side with the knees flexed Encouraging frequent visits from family and friends Administering frequent oral feedings
Positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): Extension of the esophagus through an opening in the diaphragm. Involution of the esophagus, which causes a severe stricture. Protrusion of the upper stomach into the lower portion of the thorax. Twisting of the duodenum through an opening in the diaphragm.
Protrusion of the upper stomach into the lower portion of the thorax. It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax.
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? Dyspnea and fatigue Ascites and orthopnea Purpura and petechiae Gynecomastia and testicular atrophy
Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae.
A client with liver cirrhosis develops ascites. Which medication will the nurse prepare teaching for this client? Furosemide Acetazolamide Spironolactone Ammonium chloride
Spironolactone The use of diuretic agents along with sodium restriction is successful in 90% of clients with ascites. Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide may be added but should be used cautiously because long-term use may induce severe hyponatremia (sodium depletion).
A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose? Stimulate GI peristalsis Assess for intact swallowing Assess for gastric perforation Stimulate digestive hormones
Stimulate GI peristalsis Early oral hydration stimulates GI peristalsis. The nurse would not give a client oral hydration to assess for intact swallowing as this may lead to aspiration. There is no reason to assume a client would have gastric perforation and this would not be appropriate. Digestive hormones are stimulated once peristalsis begins; however, this is not the primary purpose of early oral hydration.
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: restrict fluid intake to 1 qt (1,000 ml)/day. drink liquids only with meals. don't drink liquids 2 hours before meals. drink liquids only between meals.
drink liquids only between meals A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Lie down after meals to promote digestion." "Avoid coffee and alcoholic beverages." "Take antacids with meals." "Limit fluid intake with meals."
"Avoid coffee and alcoholic beverages." To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.
A client who is post op from bariatric surgery tells the nurse, "I love cereal for breakfast. Do you have recommendations for which kind I should eat?" How should the nurse respond? "It's best not to eat cereal after this surgery." "Choose a cereal with at least 8 grams of fiber per serving." "Choose a cereal with less than 2 grams of fiber per serving." "It's best to eat a multigrain cereal."
"Choose a cereal with less than 2 grams of fiber per serving." Cereal is acceptable post-bariatric surgery if it does not contain excess sugar and it has less than 2 grams of fiber per serving. A multigrain cereal may contain nuts or seeds, which are not recommended after bariatric surgery.
A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching? I'm going to visit my pastor weekly for a while." "I will have to take vitamin B12 shots up to 1 year after surgery." "I will call my physician if I begin to have abdominal pain." "I will weight myself each day and record the weight."
"I will have to take vitamin B12 shots up to 1 year after surgery." After a total gastrectomy, a client will need to take vitamin B12 shots for life. Dietary B12 is absorbed in the stomach, and the inability to absorb it could lead to pernicious anemia
A nurse cares for a female client of childbearing age who will undergo bariatric surgery. When teaching the client about precautions after surgery, which teaching will the nurse include that is specific to this population? "You should avoid pregnancy for at least 18 months after surgery." "After surgery, your ability to conceive is decreased considerably." "You should avoid pregnancy for at least 9 months after surgery" "After surgery, contraceptives have much less efficacy."
"You should avoid pregnancy for at least 18 months after surgery." When teaching a female of childbearing age regarding precautions after bariatric surgery, the nurse should instruct the client to avoid pregnancy for at least 18 months after surgery. The ability to conceive after weight loss surgery may improve more often than worsen.
The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed? Thoracentesis Abdominal paracentesis Abdominal CT scan Upper endoscopy
Abdominal paracentesis Abdominal paracentesis may be performed to remove ascitic fluid. Abdominal fluid is rapidly removed by careful introduction of a needle through the abdominal wall, allowing the fluid to drain.
An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: Acetaminophen Ibuprofen Dextromethorphan Benadryl
Acetaminophen Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure.
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems? Acute gastritis Duodenal ulcer Gastric cancer Gastric ulcer
Acute gastritis A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms.
A client has a family history of stomach cancer. Which factor would further increase the client's risk for developing gastric cancer? Select all that apply. High intake of fruits and vegetables Age 55 years Female gender European ancestry Previous infection with H. pylori
Age 55 years Previous infection with H. pylori The typical client with gastric cancer is between 40 and 70 years, but gastric cancer can occur in younger people. Men have a higher incidence of gastric cancer than women. Native Americans, Hispanic Americans, and African Americans are twice as likely as European Americans to develop gastric cancer. A diet high in smoked, salted, or pickled foods and low in fruits and vegetables may increase the risk of gastric cancer. Other factors related to the incidence of gastric cancer include chronic inflammation of the stomach, H. pylori infection, pernicious anemia, smoking, achlorhydria, gastric ulcers, subtotal gastrectomy more than 20 years ago, and genetics.
A nurse applies an ostomy appliance to a client who is recovering from ileostomy surgery. Which intervention should the nurse utilize to prevent leakage from the appliance? Press the adhesive faceplate from the stomal edge inward Ask the client to remain inactive for 5 minutes. Ensure that no air is trapped in the pouch Ensure that there are no holes in the pouch
Ask the client to remain inactive for 5 minutes. After applying the ostomy appliance, the nurse should ask the client to remain inactive for 5 minutes to allow body heat to strengthen the adhesive bond. The adhesive faceplate should be pressed from the stomal edge outward to prevent the formation of wrinkles. A small amount of air should also be allowed to be trapped in the pouch; liquid feces will then drain to the bottom of the pouch, placing less tension on it.
Which of the following would a nurse expect to assess in a client with peritonitis? Deep slow respirations Decreased pulse rate Hyperactive bowel sounds Board-like abdomen
Board-like abdomen The client with peritonitis would typically exhibit a rigid, board-like abdomen, with absent bowel sounds, elevated pulse rate, and rapid, shallow respirations.
A client with calculi in the gallbladder is said to have Cholecystitis Cholelithiasis Choledocholithiasis Choledochotomy
Cholelithiasis Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition.
A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? Weight loss due to malabsorption Blood and mucus in the stool Chronic constipation with sporadic bouts of diarrhea Client is awakened from sleep due to abdominal pain.
Chronic constipation with sporadic bouts of diarrhea Most clients with irritable bowel syndrome (IBS) describe having chronic constipation with sporadic bouts of diarrhea. Most clients experience various degrees of abdominal pain that defecation may relieve. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed.
A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice? Straw-colored urine Reduced hematocrit Clay-colored stools Elevated urobilinogen in the urine
Clay-colored stools Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice.
Which nursing assessment is most important in a client diagnosed with ascites? Assessment of the oral cavity for foul-smelling breath Daily measurement of weight and abdominal girth Auscultation of abdomen Palpation of abdomen for a fluid shift
Daily measurement of weight and abdominal girth Measuring and recording of abdominal girth and body weight daily are essential to assess the progression of ascites and its response to treatment
Which of the following appears to be a significant factor in the development of gastric cancer? Diet Age Ethnicity Gender
Diet Diet seems to be a significant factor: a diet high in smoked, salted, or pickled foods and low in fruits and vegetables may increase the risk of gastric cancer. The typical patient with gastric cancer is between 50 and 70 years of age. Men have a higher incidence than women. Native Americans, Hispanic Americans, and African Americans are twice as likely as European Americans to develop gastric cancer.
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes mellitus. Which of the following explains the cause of this secondary diabetes? Dysfunction of the pancreatic islet cells Ingestion of foods high in sugar Inability for the liver to reabsorb serum glucose Renal failure
Dysfunction of the pancreatic islet cells Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver.
A client with alcoholic cirrhosis develops hematemesis. For which intervention will the nurse prepare this client? Magnetic resonance imaging Endoscopy Blood transfusion Nasogastric tube insertion
Endoscopy Esophageal varices are dilated, tortuous veins that are usually found in the submucosa of the lower esophagus but may develop higher in the esophagus or extend into the stomach. This condition is almost always caused by portal hypertension, which results from obstruction of the portal venous circulation within the damaged liver. Bleeding esophageal varices are life threatening and can result in hemorrhagic shock that produces decreased cerebral, hepatic, and renal perfusion. In turn, there is an increased nitrogen load from bleeding into the gastrointestinal tract and an increased serum ammonia level, increasing the risk of encephalopathy. Endoscopy is used to identify the bleeding site, along with ultrasonography, computed tomography scanning, and angiography. A magnetic resonance imaging (MRI) is not used to diagnose or treat bleeding esophageal varices.
When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions? Frequent changes of positions Placing the patient in the prone position Perform chest physiotherapy Suction the patient every 4 hours
Frequent changes of positions Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.
Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? Hot roast beef sandwich with gravy Mashed potatoes White rice Vanilla pudding
Hot roast beef sandwich with gravy The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as roast beef because fatty foods may bring on an episode of cholecystitis.
The nurse is preparing to interview a client with cirrhosis. Based on an understanding of this disorder, which question would be most important to include? "Have you had an infection recently?" "Does your work expose you to chemicals?" "How often do you drink alcohol?" "What type of over-the-counter pain reliever do you use?"
How often do you drink alcohol?" The most common type of cirrhosis results from chronic alcohol intake and is frequently associated with poor nutrition. Although it can follow chronic poisoning with chemicals or ingestion of hepatotoxic drugs such as acetaminophen, asking about alcohol intake would be most important.
A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply. nstructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt Mobilizing the client every 2 hours Taking the client's weight every 3 to 4 days
Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt
The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? Spironolactone Cholestyramine Lactulose Kanamycin
Lactulose Lactulose is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients.
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? Coagulation studies Magnetic resonance imaging Radioisotope liver scan Liver biopsy
Liver biopsy A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.
A nurse cares for a client who is post op bariatric surgery. Which position will the nurse place the client in order to best promote comfort?
Low Fowler's Positioning the client in low Fowler's position best promotes comfort in the client who is post op bariatric surgery. In addition to decreasing incisional pain, this position also promotes gastric emptying.
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? Low residue Low protein Calorie restriction Iron restriction
Low residue Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.
A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? Controlling bleeding Maintaining the airway Maintaining fluid volume Relieving the client's anxiety
Maintaining the airway Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life.
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? Report the condition to the physician immediately. Measure abdominal girth according to a set routine. Provide the client with nonprescription laxatives. Ask the client about food intake.
Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately.
A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? Auscultate the abdomen for bowel sounds every 4 hours Measure abdominal girth every shift Monitor for reports of nausea and vomiting Measure blood glucose concentration every 4 to 6 hours
Measure blood glucose concentration every 4 to 6 hours Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.
A nurse is planning care for a client who will be arriving to the unit postoperatively from bariatric surgery. In an effort to decrease the risk of venous thromboembolism (VTE), which health care provider orders does the nurse anticipate? Mechanical compression and prophylactic anticoagulation Mechanical compression only Prophylactic anticoagulation only Early ambulation only
Mechanical compression and prophylactic anticoagulation Both mechanical compression (intermittent pneumatic compression devices) and prophylactic anticoagulation with low molecular weight heparin agents are prescribed in the client who is postoperative bariatric surgery.
A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply. Nizatidine Lansoprazole Famotidine Cimetidine Esomeprazole
Nizatidine Famotidine Cimetidine H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease
During a home visit the nurse notes that a client recovering from peptic ulcer disease is experiencing cool clammy skin and has a heart rate of 96 beats a minute. Which action will the nurse take Notify the primary health care provider. Provide a dose of a proton pump inhibitor. Encourage the client to drink a warm beverage. Discuss the types of foods the client has been eating.
Notify the primary health care provider. The client with peptic ulcer disease is demonstrating signs of hemorrhage which include cool skin and tachycardia. The health care provider should be immediately notified.
A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer. Nizatidine Cimetidine Famotidine Omeprazole
Omeprazole Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.
What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? Pad the side rails on the bed Apply soft wrist restraints Raise all four side rails on the bed Prevent visitors, so as not to agitate the client
Pad the side rails on the bed Padding the side rails can reduce injury if the client becomes agitated or restless.
The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition? Pernicious anemia Systemic infection Peptic ulcers Colostomy
Peptic ulcers Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.
A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? Duodenal ulcers Hemorrhoids Weight gain Polyps
Polyps Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? Relieving abdominal pain Preventing fluid volume overload Maintaining adequate nutritional status Teaching about the disease and its treatment
Relieving abdominal pain The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? Monitor pulse oximetry every hour. Withhold oral feedings for the client. Instruct the client to avoid coughing. Reposition the client every 2 hours.
Reposition the client every 2 hours. Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis.
In what location would the nurse palpate for the liver? Left lower quadrant Left upper quadrant Right lower quadrant Right upper quadrant
Right upper quadrant The liver may be palpable in the right upper quadrant. A palpable liver presents as a firm, sharp ridge with a smooth surface.
A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? Serum calcium Serum bilirubin Serum amylase Serum potassium
Serum amylase Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase.
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? Three meals and 120 ml fluid daily Three meals and three snacks and 120 mL fluid daily Six small meals and 120 mL fluid daily Six small meals daily with 120 mL fluid between meals
Six small meals daily with 120 mL fluid between meals After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.
A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? Suggest fluid intake of at least 2 L/day Instruct the client to avoid prune or apple juice Assist the client regarding the correct diet or to minimize food intake Instruct the client to keep a record of food intake
Suggest fluid intake of at least 2 L/day The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care? Test all stools for occult blood. Administer topical ointment to the rectal area to decrease bleeding. Prepare the client for a gastrostomy tube placement. Administer morphine (Duramorph PF) routinely, as ordered.
Test all stools for occult blood. Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum
A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? The client's hepatic function is decreasing. The client didn't take his morning dose of lactulose (Cephulac). The client is relaxed and not in pain. The client is avoiding the nurse.
The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction.
Which of the following is the most successful treatment for gastric cancer? Removal of the tumor Chemotherapy Radiation Palliation
There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely.
The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? To drain the pancreatic bed To aid opening up of pancreatic duct To prevent the occurrence of fibrosis To avoid inflammation of the pancreas
To avoid inflammation of the pancreas Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.
The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? To decrease metabolism To depress the central nervous system and increase the pain threshold To reduce gastric and pancreatic secretions To relieve nausea and vomiting
To reduce gastric and pancreatic secretions Anticholinergic medications reduce gastric and pancreatic secretion.
The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation? Alcohol consumption Activity levels Usual pattern of elimination Current medications
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. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.
The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelithiasis can interfere with the absorption of Vitamin A Vitamin B6 Vitamin B12 Vitamin C
Vitamin A Obstruction of bile flow interferes with absorption of the fat-soluble vitamins A, D, E, and K. Clients may exhibit deficiencies of these vitamins if biliary obstruction has been prolonged. Vitamins B6, B12, and C are not fat soluble.
A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing? Riboflavin deficiency Folic acid deficiency Vitamin A deficiency Vitamin K deficiency
Vitamin K deficiency Vitamin K deficiency results in hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.
The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? Watery diarrhea Vomiting Ringing in the ears Asterixis
Watery diarrhea The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? Abdominal distention, elevated temperature, weakness before eating Constipation, rectal bleeding following bowel movements Persistent loose stools, chills, hiccups after eating Weakness, diaphoresis, diarrhea 90 minutes after eating
Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported.
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: a sedentary lifestyle and smoking. a history of hemorrhoids and smoking. alcohol abuse and a history of acute renal failure. alcohol abuse and smoking.
alcohol abuse and smoking. The nurse should mention that risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress.
Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients: cannot tolerate high-glucose concentration. are at risk for gallbladder contraction. are at risk for hepatic encephalopathy. can digest high-fat foods.
cannot tolerate high-glucose concentration. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage.
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cirrhosis. peptic ulcer disease. appendicitis. cholelithiasis.
cirrhosis. Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis.
A preoperative client scheduled to have an open cholecystectomy says to the nurse, "The doctor said that after surgery, I will have a tube in my nose that goes into my stomach. Why do I need that?" What most common reason for a client having a nasogastric tube in place after abdominal surgery should the nurse include in a response? decompression instillation gavage lavage
decompression Negative pressure exerted through a tube inserted in the stomach removes secretions and gaseous substances from the stomach, preventing abdominal distention, nausea, and vomiting.
The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience vomiting. hemorrhage. pain 2 to 3 hours after a meal. weight loss.
pain 2 to 3 hours after a meal. The client with a duodenal ulcer often awakens between 1 and 2 with pain, and ingestion of food brings relief. Vomiting is uncommon in the client with duodenal ulcer. Hemorrhage is less likely in the client with duodenal ulcer than in the client with gastric ulcer. The client with a duodenal ulcer may experience weight gain.
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is elevated liver enzymes and low serum protein level. subnormal serum glucose and elevated serum ammonia levels. subnormal clotting factors and platelet count. elevated blood urea nitrogen and creatinine levels and hyperglycemia.
subnormal serum glucose and elevated serum ammonia levels. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness
