LSII Exam 4

A client in just beginning her third trimester complains to the nurse about having frequent heartburn. She states concerns about taking medications during pregnancy. What would be the most appropriate suggestion the nurse should make for this client? "Begin with lifestyle modifications such as avoiding spicy foods, no eating after 7PM, and elevating the HOB to sleep." "Symptoms can be best managed with over the counter antacids; take them as needed until the symptoms resolve" "Eat larger meals, but not late in the evening." "Medications for these symptoms are very safe during pregnancy and you can buy them over the counter or get a prescription."

"Begin with lifestyle modifications such as avoiding spicy foods, no eating after 7PM, and elevating the HOB to sleep."

The nurse conducts an evaluation after completing a training session for community members on ways to prevent nephritis. When evaluating the success of this session, what responses from the community members would indicate that learning has been successful? "One way to help avoid nephritis is by not drinking milk." "Controlling high blood pressure is important in the prevention of nephritis." "I should limit my alcohol intake to reduce the risk of nephritis." "Practicing good hygiene will prevent nephritis."

"Controlling high blood pressure is important in the prevention of nephritis."

The nurse provides discharge teaching for a client with peptic ulcer disease (PUD). Which client statement indicates that teaching has been effective? "I will limit my intake of coffee." "I will drink more milk if I eat spicy foods." "I will take ibuprofen (Motrin) for my headaches." "I need to join a gym and increase my exercise."

"I will limit my intake of coffee."

The nurse has implemented a care plan for an adult client with gastroesophageal reflux disorder (GERD). On the next clinic visit, which statement by the client indicates adherence to the plan of care? "I've lost 6 pounds because I eat every 3 hours and never before bed." "I can wear snug spandex camisoles if I feel comfortable." "I have switched from margaritas to wine." "I take a Tums with the ranitidine to make it work better."

"I've lost 6 pounds because I eat every 3 hours and never before bed." Appropriate client outcomes are freedom from pain and knowledge of lifestyle changes to manage GERD. Weight loss, small, frequent meals, and avoiding lying down within 3 hours of eating indicate correct management. Tight-fitting clothing such as spandex camisoles can worsen GERD, regardless of whether the client feels comfortable wearing them. Changing from margaritas to wine will not improve GERD. Antacids such as Tums should be avoided within 1 hour before or after an H2-receptor blocker like ranitidine.

Which question best helps the nurse establish a common cause of recurrent urinary tract infections (UTIs) in a preadolescent female client? "Do you have a family history of urinary problems?" "How often do you shower?" "In what direction do you wipe after a bowel movement?" "When was your last UTI?"

"In what direction do you wipe after a bowel movement?"

A new mother brings a male infant, 2 weeks old, to the pediatric clinic for a checkup. The mother is concerned that the infant may be at risk for pyloric stenosis due to his age and because her husband had surgery for the condition when he was an infant. Which responses by the nurse are the most appropriate based on this data? "Due to your age, your son is at an increased risk for the condition." "Your baby has a greater risk for the condition due to a familial history." "As long as your baby has bowel movements there is nothing to worry about." "Your baby would have an increased risk if the infant was a girl."

"Your baby has a greater risk for the condition due to a familial history." The infant is at a greater risk for developing pyloric stenosis because of the familial history. Pyloric stenosis is more common in males than females. The mother's age is not correlated with an increased risk of pyloric stenosis. While bowel movements are important, this is not indicative of not having pyloric stenosis.

The nurse is reviewing information about four clients who are coming in to the office today due to concerns about bowel elimination. Which of these clients is most likely to have a daily stool softener added to their treatment regimen? A 92-year-old client who experiences frequent leakage of feces from the anus A 28-year-old client who is anemic and has blood in the stool A 43-year-old client who takes opioid medication for chronic pain A 3-month-old client who is exclusively breastfed

A 43-year-old client who takes opioid medication for chronic pain

A nurse recommends a gluten-free diet to a client recently diagnosed with celiac disease. The client says that she wants to become pregnant and asks how a gluten-free diet might aid in that. What is not a benefit for this client of a gluten-free diet? A gluten-free diet increases the probability that the child's birth weight will be healthy. A gluten-free diet may improve fetal bone development. A gluten-free diet will lower the risk of miscarriage. A gluten-free diet will lower the risk of infertility.

A gluten-free diet may improve fetal bone development.

The nurse admits a hypertensive client diagnosed with glomerulonephritis. Which medication should the nurse expect to be ordered for the​ client? ACEI Beta Blocker Vasodilator Steroid

ACEI

A nurse is caring for an infant postsurgery for pyloric stenosis. Which nursing interventions are appropriate when providing care for this infant? Select all that apply. Administer analgesics, per order. Monitor temperature once per shift. Instruct the parents on proper diapering to avoid pressure over the incision. Teach the parents to remove the Steri-Strips during the infant's first bath postsurgery. Encourage swaddling and rocking to facilitate relaxation.

Administer analgesics, per order. Instruct the parents on proper diapering to avoid Encourage swaddling and rocking to facilitate relaxation. Nursing interventions for an infant postsurgery for pyloric stenosis include administering analgesics, per order; instructing the parents on proper diapering to avoid pressure on the incision; and encouraging swaddling and rocking to facilitate relaxation. Postoperatively the incision is covered with collodion or Steri-Strips and should be kept clean and dry. The parents should be taught to allow the Steri-Strips to come off on their own. The infant's temperature should be monitored every 4 hours due to the increased risk for infection.

The nurse is providing teaching to the family of an older adult client with a urinary tract infection (UTI). Which common early symptom that is likely to occur in older adults should the nurse stress? Blood in the urine Rapidly rising fever Alteration in cognition Alteration in metabolism

Alteration in cognition

The nurse is caring for a group of clients on a medical-surgical unit. Which client does the nurse anticipate to be at the greatest risk for alterations in urinary elimination? A client who had bladder cancer and now has a newly created ileal conduit The client with hypertension An 80-year-old male client reporting frequent urination at night A 25-year-old female client with low self-esteem

An 80-year-old male client reporting frequent urination at night

The nurse is planning a teaching session regarding peptic ulcers for the residents of an assisted-living complex. Which concepts about peptic ulcer disease should the nurse include in the presentation to the residents? Select all that apply. An individual with a peptic ulcer will most likely experience pain when the stomach is empty. A sign of a peptic ulcer may be serious gastrointestinal bleeding. Many peptic ulcers are infected with Helicobacter pylori (H. pylori) and are treated with antibiotics. Gastric ulcers are more common than duodenal ulcers. A colonoscopy is the required test used to diagnose the presence of a gastric ulcer.

An individual with a peptic ulcer will most likely experience pain when the stomach is empty. A sign of a peptic ulcer may be serious gastrointestinal bleeding. Many peptic ulcers are infected with Helicobacter pylori (H. pylori) and are treated with antibiotics. The client with a peptic ulcer may be largely asymptomatic until there is an episode of gastrointestinal bleeding. Duodenal ulcers are more common than gastric ulcers. The individual who has a peptic ulcer will most likely have abdominal pain when the stomach is empty. Tests used to diagnose a gastric ulcer include endoscopy and H. pylori testing. Peptic ulcers that are infected with H. pylori will often be treated with antibiotics.

The nurse is caring for a newborn infant who has not yet voided in the first 48 hours of life. Which action should the nurse​ take? Assess for bladder distention. Wait another 12 hours. Insert a urinary catheter. Initiate IV fluid therapy.

Assess for bladder distention.

A home healthcare nurse is providing care to an older adult client who lives alone and has limited financial resources. The client has a history of celiac disease. When planning care for this client, which nursing diagnoses are appropriate? Select all that apply. Chronic Pain Risk for Constipation Risk for Imbalanced Fluid Volume Imbalanced Nutrition: Less than Body Requirements Diarrhea

Chronic Pain Risk for Imbalanced Fluid Volume Imbalanced Nutrition: Less than Body Requirements Diarrhea Client with celiac disease often have nutritional imbalance, including anemia and vitamin deficiencies; impaired absorption of fluids and electrolyte, which leads to diarrhea and fluid imbalance; and pain related to abdominal bloating and cramping. Constipation is not a normal manifestation of celiac disease.

Select the risk factors for peptic ulcer disease (PUD). High socioeconomic status Being under age 20 Chronic aspirin use H-pylori infection Cigarette smoking A member of the household has H-pylori infection Diet low in fiber

Chronic aspirin use H-pylori infection Cigarette smoking A member of the household has H-pylori infection

List at least 4 things that can be done to reduce the risk of developing a CAUTI in the in-patient setting.

Clean the Catheter and Peri area when soiled and/or every 12 hours. Keep the drainage bag below the bladder at all times Assess the need for the catheter and remove it as soon as the patient is able to void without assistance Use strict aseptic technique when inserting the catheter

The healthcare provider prescribes an indwelling urinary catheter for a client with urinary retention. Which intervention, along with strict aseptic technique, will decrease the risk of infection for this procedure? Irrigating the catheter with sterile saline on a daily basis Inflating the balloon while the catheter is in the urethra Instructing the client to void around the catheter Cleansing the urethral meatus with betadine

Cleansing the urethral meatus with betadine

What instructions from the nurse would be most beneficial in preventing UTI in the future? Only void if you feel your bladder is full Complete the entire course of antibiotics even if symptoms subside. Use gentle soap to clean your skin Drink 6 oz. of cranberry juice daily

Complete the entire course of antibiotics even if symptoms subside.

The nurse has identified the diagnosis Excess Fluid Volume as appropriate for a client with acute glomerulonephritis. What should the nurse assess to obtain the most accurate indication of this client's fluid balance? Vital signs Intake and output records Serum sodium levels Daily weight

Daily weight

A newly diagnosed client with Celiac Disease needs a lesson on diet modifications to help manage the illness. What topic would not be part of this discussion? Decreasing calories and protein in the diet Use of supplements for vitamins and minerals Consultation with a dietician Increasing awareness of hidden sources of gluten in foods

Decreasing calories and protein in the diet

The nurse is caring for an African American client with nephritis. When planning this client's care, the nurse should include interventions aimed at preventing which of the following long-term complications? Hypertension End-stage renal disease Congestive heart failure Diabetes mellitus

End-stage renal disease

The nurse admits a client diagnosed with glomerulonephritis. The nurse should identify which characteristic that occurs with​ glomerulonephritis? (Select all that​ apply.) Gradual decline in renal function Entire nephrons eventually being lost Symmetrical decrease in the size of the kidneys Slow, progressive destruction of the glomeruli Surfaces of the kidneys becoming hard and bumpy

Gradual decline in renal function Entire nephrons eventually being lost Symmetrical decrease in the size of the kidneys Slow, progressive destruction of the glomeruli

The nurse admits a client to the medical unit for a urinary disorder. Which questions are appropriate for the nurse to include when assessing the client's voiding pattern? (Select all that apply.) How many times do you urinate in a 24-hour period? Has your pattern of urination changed recently? How often do you get out of bed at night to urinate? What color is your urine? Does your urine have any type of odor? Is your urine clear, cloudy, or have any sediment in it? 0% correct

How many times do you urinate in a 24-hour period? Has your pattern of urination changed recently? 0% correct

The nurse is explaining the alteration in normal function to a client recently diagnosed with gastrointestinal reflux disease (GERD). Which etiology contributing to GERD will the nurse include in the teaching session? Transient constriction of the lower esophageal sphincter Incompetent lower esophageal sphincter Decreased pressure within the stomach Prolonged constriction of the upper esophageal sphincter

Incompetent lower esophageal sphincter An incompetent lower esophageal sphincter remains open, allowing gastric acid to reflux into the esophagus. The lower esophageal sphincter is normally constricted except during swallowing. Increased pressure in the stomach can cause acid to reflux into the esophagus. The action of the upper esophageal sphincter is not a cause of GERD.

A 42-year-old male client is diagnosed with adult pyloric stenosis. Which of the following symptoms would the nurse least expect to encounter in this client? Increase of appetite Nausea Upper abdominal pain Weight loss

Increase of appetite The nurse would not expect to find an increase of appetite in this client. Symptoms of adult pyloric stenosis include weight loss, easy satiety, loss of appetite, and gradual increase of upper abdominal pain. Nausea and vomiting are also common.

An infant is suspected of having pyloric stenosis. What would the nurse suspect to find while collecting the health history? Infant has consistent yellowish stools. Infant vomits frequently with feeding and is not gaining weight. Infant does not act hungry and feeds for a short time. The infant is 1 week old and spits up during the morning feeding.

Infant vomits frequently with feeding and is not gaining weight.

The nurse is teaching a client with celiac disease about the disease process. Which reason should the nurse provide as the cause for the reaction occurring in the small bowel with this ​disorder? Nervous system Cellular Allergic stress Inflammatory

Inflammatory ​Rationale: The immune response prompts an inflammatory response in the small​bowel, resulting in loss of villi and microvilli. The reaction in this disease process does not occur because of an​ allergy, an issue at the cellular​ level, or a problem with the nervous system.

An older adult African American client with a history of celiac disease presents with abdominal cramps, pain, and diarrhea. The client denies the use of alcohol, but states, "My favorite foods are steak, cheese, and ice cream." Based on this data, which condition does the nurse suspect? Lactase deficiency Appendicitis Food poisoning Acute pancreatitis

Lactase deficiency The most common risk factor for pancreatitis is alcohol abuse. Appendicitis usually involves loss of appetite and nausea and/or vomiting soon after abdominal pain begins. Lactose intolerance is more common in Native Americans, Asians, Hispanics, and African Americans and in those with a history of celiac disease. Food poisoning generally causes some nausea and vomiting.

A client with lactose intolerance does not want to give up dairy in their diet. A management strategy would include: Surgery to remove part of the bowel Lactose free products Increase the amount of iron in the diet Avoid anti diarrhea medications Lactose enzymes

Lactose free products

The healthcare provider prescribes an indwelling urinary catheter for a client with urinary retention. Which intervention has not shown to decrease the risk of infection following this procedure? Maintain tension on the catheter to keep the balloon on the bottom of the bladder Ensure the collection bag is always lower than the level of the bladder Assess the need for the catheter and remove it as soon as possible Perform peri and catheter care using catheter care wipes

Maintain tension on the catheter to keep the balloon on the bottom of the bladder

A realistic goal that would indicate a patient's nephritis is improving would be The patient consumes at least 75% for the diet Temperature of 101.0 F Maintain urine output of ≥0.5mL/kg/hr The blood pressure remains stable within normal range

Maintain urine output of ≥0.5mL/kg/hr

Fecal impaction is a mass or collection of hardened feces in the folds of the rectum or colon as a result of prolonged retention and accumulation of fecal material. Which clinical manifestation is common in cases of fecal impaction? Passage of lumpy stools that are hard and dry Passage of liquid, foul-smelling fecal material in the absence of formed stool Passage of soft, formed stools No passage of stool or fecal material of any kind

Passage of liquid, foul-smelling fecal material in the absence of formed stool Clients with a fecal impaction pass liquid, foul-smelling fecal material in the absence of formed stool; this is the liquid portion of the feces that seeps around the impacted mass. Passing no stool or fecal material is indicative of an obstruction. Soft, formed stools are generally considered normal. Lumpy stools that are hard and dry are indicative of constipation.

A pediatric client is diagnosed with gastroesophageal reflux disorder (GERD). The nurse is observing a return demonstration of the caregiver preparing and feeding the infant formula. Which observation demonstrates correct procedure for preventing GERD symptoms? Thinning the formula with water prior to feeding Positioning the infant upright for a minimum of 30 minutes Warming the formula prior to feeding Burping the infant after 4 ounces of formula are taken

Positioning the infant upright for a minimum of 30 minutes

The nurse is caring for a client newly admitted to the medical-surgical unit with glomerulonephritis. Which classic manifestations of this disorder should the nurse expect to assess in this client? Select all that apply. Proteinuria Weight loss Hematuria non intact skin Edema

Proteinuria Hematuria Edema

The nurse is planning care for a client who has fecal incontinence. Which intervention should the nurse​ include? (Select all that​ apply.) Provide privacy when using the bathroom. Insert a glycerin suppository at the same time every morning per order. Demonstrate the correct positioning for bowel evacuation to avoid straining. Assist the client to the bathroom each day around the​ client's standard time of defecation. Administer a bulk laxative per order.

Provide privacy when using the bathroom. Insert a glycerin suppository at the same time every morning per order. Assist the client to the bathroom each day around the​ client's standard time of defecation.

Parents of a child diagnosed with celiac disease have requested guidance on how to implement an appropriate diet. In addition to a list of foods to include and exclude, which interventions by the nurse are appropriate? (Select all that apply.) Providing a referral to support groups Implementing a recommended exercise program Training on how to read food labels Obtaining a dietary prescription Encouraging the use of a gluten-free cookbook

Providing a referral to support groups Training on how to read food labels Obtaining a dietary prescription Encouraging the use of a gluten-free cookbook

The nurse is providing care to a client who is experiencing urinary incontinence. Which independent nursing intervention is the most appropriate for this client? Instructing on self-catheterization Teaching hygiene care Providing catheter care Encouraging increased fluid intake

Teaching hygiene care

An adult client is admitted to the hospital with a diagnosis of kidney stones. The healthcare provider prescribes IV fluids, x-rays, blood work, and a Foley catheter for the client. The nurse is caring for the client 3 days after admission and documents morning vital signs of 101°F, heart rate 92, respirations 25, and blood pressure 120/80. The urinary output has decreased, and the urine is cloudy and dark amber. Based on this data, which conclusion by the nurse is the most appropriate? The client has developed nephritis The client is in acute renal failure. The client has a probable urinary tract infection. The client has developed a respiratory infection

The client has a probable urinary tract infection.

The nurse is caring for a client who receives H2-receptor antagonists for the treatment of peptic ulcer disease. Based on the nursing diagnosis Risk for Bleeding, which assessment finding should the nurse report immediately to the healthcare provider? The client reports pain after 24 hours of treatment. The client reports that he took Tums antacids with his H2-receptor antagonist. The client reports episodes of melena. The client reports that he is constipated.

The client reports episodes of melena. Melena could indicate GI bleeding and should be reported to the physician immediately. The client may still experience pain for several days with this type of medication. Taking Tums antacids with an H2-receptor antagonist will cause deceased absorption of the H2-receptor antagonist, but this does not need to be reported to the healthcare provider; rather, the nurse should educate the client. Constipation is a common side effect that does not need to be immediately reported to the healthcare provider.

The nurse is caring for a client with urinary retention. Which action should the nurse include to promote normal​ voiding? (Select all that​ apply.) Lying the client in bed flat to use the bedpan Running cool water over the perineum Turning the sink on to run water Providing privacy Using a sitz bath

Turning the sink on to run water Providing privacy Using a sitz bath

The nurse is providing care to an elderly female client who is diagnosed with stress incontinence. Which data would nurse expect to collect during the client's health history and physical assessment? Select all that apply Urine leakage while laughing Urine leakage while talking Urine leakage while coughing A urinary catheter Skin breakdown on the buttock

Urine leakage while laughing Urine leakage while coughing Skin breakdown on the buttock Stress incontinence involves a small leakage of urine when a client laughs, coughs, or lifts something heavy, not if a client just carries on a conversation. A client with incontinence would wear some kind of undergarment pad; a urinary catheter is not an expected finding. If the client has been experiencing incontinence, the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the skin.

For a 9-month-old infant, which finding is inconsistent with GERD? Wheezing Vomiting Weight gain Irritability

Weight gain

A client with Helicobacter pylori is prescribed bismuth (Pepto-Bismol) along with what other treatments? antacids and iron supplements metoprolol and sucralfate. amoxicillin and clarithromycin antispasmodic and antibiotic

amoxicillin and clarithromycin Bismuth compounds (Pepto-Bismol) are added to the dual antibiotic regimen to inhibit bacterial growth. Bismuth compounds also stimulate mucosal bicarbonate and prostaglandin production to promote ulcer healing. Most common antibiotics prescribed are amoxicillin/clarithromycin/metronidazole. The other medications are not part of the treatment of Helicobacter pylori.

Which of the following is true about Short Bowel Syndrome? TPN is first treatment option management focuses on symptoms and nutritional supplementation severity has in inverse relationship to the amount of bowel resected. results from an autoimmune response resulting in chronic inflammation

management focuses on symptoms and nutritional supplementation

The most common cause of UTI in male infants is obstructive structural defects poor hydration contamination from stool incontinence soaps causing irritation during bathing

obstructive structural defects

The most common type of upper urinary tract infection that results from bacteria ascending to the kidney from the lower urinary tract is urethritis. cystitis. prostatitis. pyelonephritis.

pyelonephritis.

The most common source for bacteria that cause a urinary tract infection is unwashed hands. synthetic clothing such as underwear. the mucous membranes of the GI tract, transferred to the perineal area. a catheter.

the mucous membranes of the GI tract, transferred to the perineal area.

A client presents with acute constipation for the second time in two months. The physician orders a diagnostic barium enema. Based on the testing order, the nurse understands that the client's condition is likely associated with: the structure of the bowel or the presence of tumors or diverticula. completeness of bowel elimination. the efficiency with which the food moves through the gastrointestinal tract. rectal muscle contractions.

the structure of the bowel or the presence of tumors or diverticula. A barium enema is used to identify bowel structure, tumors, or diverticula; thus, the nurse understands that one of these is likely a causative factor in the client's condition. A defecography is used to assess rectal muscle contractions. An anorectal manometry is used to assess the completeness of bowel elimination. A colorectal transit study is used to determine how efficiently food moves through the gastrointestinal tract.

What would be a positive indication that a patient has a UTI? glucose is present in urine urine is dark amber WBCs are present in urine urine culture has E coli growth

urine culture has E coli growth