Med Surg Chapter 57

A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? A) Distended abdomen B) Temperature of 100.0 F (37.8 C) C) Loose and bloody stool D) Lower abdominal cramps

A) Distended abdomen The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client had developed an obstruction of the large bowel and the clients provided should notified right away. Low grade fever, bloody diarrhea and abdominal cramps are common symptoms of Crohn's disease.

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this clients teaching? A) Drink plenty of fluids to prevent dehydration B) You should only drink 1 liter of fluids daily C) Increase your protein intake by drinking more milk D) Sips of cola may help to relieve your nausea

A) Drink plenty of fluids to prevent dehydration. The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

A nurse cares for a client with ulcerative colitis. The client states I feel like I am ?? controlling my life. How should the nurse respond? A) Lets discuss potential factors that increase your symptoms B) If you take the prescribed medications you will no longer have diarrhea C) To decrease distress do not eat anything before you go out D) You must retake control of your life I will consult a therapist to help

A) Lets discuss potential factors that increase your symptoms Clients with UC often express that the disorder is disruptive to their lives. Stress increase symptoms. These factors should be identified so that the client will have more control their condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist can assist the client this is not an appropriate response.

A nurse cares for a client who has a giardia infection. Which medication should the nurse expect to be prescribed for this client? A) Metronidazole (Flagyl) B) Ciprofloxacin (Cipro) C) Sulfasalazine (Azulfidine) D) Ceftriaxone (Rocephin)

A) Metronidazole (Flagyl) Metronidazole is the drug of choice for a giardia infection. Ciprofloxacin and ceftriaxone are d=for bacterial infections. Sulfasalazine is used for UC and Crohn's disease.

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical finding should alert the nurse to urgently contact the provider? A) Pale and bluish stoma B) liquid stool C) Ostomy pouch intact D) Blood smeared output

A) Pale and bluish stoma The nurse should assess the stoma for color and contact the provider if the stoma is pale an bluish. The nurse should expect the client to have an intact ostomy pouch with dark green liquid that contains some blood.

A nurse reviews the chart of a client who has Crohn's disease and a draining fistula what should alert the nurse to urgently contact the provider for additional prescriptions? A) Serum potassium of 2.6 mEq/l B) Client ate 20% of breakfast meal C) WBC of 8200/mm3 D) Clients weight decreased by 3 pounds

A) Serum potassium Fistulas place the client with Crohn's disease at risk for hypokalemia which can lead to serious complications. This potassium level is low and should cause the nurse to intervene. The WBC and other two finding are abnormal and warrant interventions but the potassium level takes priority.

A Nurse assess a client who has appendicitis. Which clinical manifestation should the nurse expect to find? A) Severe steady right lower quadrant pain B) Abdominal pain associated with nausea and vomiting C) Marked peristalsis and hyperactive bowel sounds D) Abdominal pain that increases with knee flexion

A) Severe steady right lower quadrant pain Right lower quad pain specifically at McBurney's point is characteristics of appendicitis. Usually if nausea and vomiting begin first the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.

A nurse assesses a client with UC which complications are paired correctly in the physiologic process? Select all A) Lower gastrointestinal bleeding erosion of the bowel wall B) Abscess formation, localized pockets of infection develop in the ulcerated bowel lining C) Toxic megacolon transmural inflammation resulting in pyuria and fecaluria D) Nonmechanical bowel obstruction paralysis of colon resulting from colorectal cancer E) Fistula dilation and colonic ileus caused by paralysis of the colon

A-B-D Lower GI bleeding can lead o erosion of the bowel wall Abscesses are localized pockets to develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon from colorectal cancer. When the inflammation is transmural fistulas can occur between the resulting in pyuria and fecaluria paralysis of the colon causing dilation and subsequent as a toxic megacolon

A nurse assesses a client with peritonitis which clinical manifestation should the nurse expect? Select all A) Distended abdomen B) Inability to pass flatus C) Bradycardia D) Hyperactive bowel sounds E) decreased urine output

A-B-E a client with peritonitis may present with a distended abdomen diminished bowel sounds inability to pass flatus or feces , tachycardia and decreased urine output secondary to dehydration bradycardia and bowel sounds are not associated with peritonitis

After teaching a client with an fissure a nurse assesses the clients understanding. What statement indicates that the client correctly understands the teaching select all that apply) A) Taking a warm sitz bath several times a day B) Utilizing a daily enema to prevent constipation C) Using bulk producing agents to aid in elimination D) Self administering anti-inflammatory suppositories E) Taking a laxative each morning

A-C-D Taking warm spitz bath each day using bulk producing agents and administering inflammatory suppository are all appropriate actions for the client with an anal fissure. The client should use laxatives to promote elimination but rather should rely on bulk producing agents such as psylliumcilloid (Metamucil)

A nurse teaches a client to avoid becoming ill with Salmonella infection agian. Which should the include in the clients teaching? Select all that apply) A) Wash leafy vegetables carefully before eating or cooking them B) Do not ingest water from the garden hose or the pool C) Wash your hands before and after using the bathroom D) Be sure your meat is cooked to the proper temperature E) Avoid eating eggs that are sunny side up or undercooked

A-C-D-E Salmonella is usually contracted via contaminated eggs, beef, poultry and green leafy vegetables. Wash hands before and after using the restroom. Make sure meats and eggs are cooked properly, keep flies off food [

A nurse teaches a community group about food poisoning and gastroenteritis. Which statement should the nurse include in this groups teaching? A) Rotavirus is more common among infants and younger children B) E.coli diarrhea is transmitted by contact with infected animals C) To prevent E.coli infection don't drink water when swimming D)Clients who have botulism should be quarantined within their home E) Parasitic diseases may not show up for 1-2 weeks after infection

A-C-E Rotavirus is more among the youngest of clients. Not drinking water while swimming will prevent E.coli infection. Parasitic disease may take up to 2-3 weeks to become symptomatic Botulism need to be hospitalized to monitor for respiratory \failure and paralysis. Escherichia transmitted by contact with infected animals

A nurse teaches a community group ways to prevent E.coli infection. Which statements should the nurse include in this groups teaching? A) Wash your hands after contact with animals B) It is not necessary to buy a meat thermometer C) Stay away from people who are ill with diarrhea D) Use separate cutting boards for meat and vegetables E) Avoid swimming in backyard pools and using hot tubs.

A-D Washing hands after contact with animals and using separate cutting boards for meat and other surfaces to prevent E.coli infection. The other statements are not related to preventing E.coli infection.

A nurse cares for an older adult client who has Salmonella food poisoning. The clients vital signs are heart rate: 102 beats/min, Blood pressure: 98/55 mm/hg, respiratory rate :22 breaths/min, and oxygen saturation 92. Which action should the nurse complete first? A) Apply oxygen via nasal cannula B) Administer intravenous fluids C) Provide perineal care with premedicated wipe D) Teach proper food preparation to prevent contamination

B) Administer intravenous fluids Dehydration caused by diarrhea can occur quickly in older adults with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the clients understanding. Which statement by the client indicated a need for additional teaching? A) Ill rinse my rectal area with warm water after each stool and apply zinc oxide ointment. B) I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel. C) I must take a sitz bath thee times a day and then pat my rectal area gently but thoroughly to make sure I am dry D) I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment

B) I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel. Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

After teaching a client who is prescribed adalimumab (Humira) from severe ulcerative colitis the nurse assess the clients understanding. Which statement made by the client indicates a need for additional teaching? A) I will avoid large crowds and people who are sick. B) I will take this medication with my breakfast each morning C) Nausea and vomiting are common side effects of this drug D) I must wash my hands after I play with my dog

B) I will take this medication with my breakfast each morning. Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick and should practice good handwashing

After teaching a client who was hospitalized for salmonella food poisoning, a nurse assesses the clients understanding. Which statements made by the client indicates a need for additional teaching? A) I will let my husband do all of the cooking for my family B) Ill take the ciprofloxacin until the diarrhea has resolved C) I should wash my hands with antibacterial soap before each meal D) I must place my dishes into the dishwasher after each meal

B) Ill take the ciprofloxacin until the diarrhea has resolved. Ciprofloxacin should be taken for 10-14 days to treat Salmonella infection and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection mat spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carries for up to 1 year.

A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. What should the nurse indicate is the priority action in this clients plan of care? A) Low fiber diet B) Skin protection C) Antibiotic administration D) Intravenous glucocorticoids

B) Skin protection Protecting the skin is the priority action for a client who has a heavily draining fistula enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. Care for a client who has Crohn's disease includes adequate nutrition focused on high calorie high vitamin and low fiber meals antibiotic administration and glucocorticoids.

A nurse assesses a client who is hospitalized for botulism . The clients vitals signs are temp 99.8 F, heart rate 100 betas/min, respiratory rate 10 breaths/min and blood pressure 100/60 what action should the nurse take? A) Decrease stimulation and allow the client to rest. B) Stay with the client while another nurse calls the provider C) Increase the clients intravenous fluid replacement rate D) Check the clients blood glucose and administer orange juice

B) Stay with the client while another nurse calls the provider a client with botulism is at risk for respiratory failure. This clients respiratory rate is slow which indicates impending respiratory distress or failure. The nurse should remain with the client while the other notifies the provider. The nurse should monitor and document the IV infusion per protocol not require additional intravenous fluids. Allowing the client to rest or checking the blood glucose or administering orange juice are not appropriate actions.

A nurse care for a client with a new ileostomy. The client states I don't think my friends will like me with this ostomy. How should the nurse respond? A) Your friends will be happy that you are alive. B) Tell me more about your concerns C) A therapist can help you resolve your concerns D) With time you will accept your new body

B) Tell me more about your concerns Social anxiety and apprehension are common concerns with a new ileostomy. The nurse should encourage client to discuss concerns. The nurse should not minimize the client concerns or provide false

After teaching a client who has a new colostomy the nurse provides feedback based on complete self care activities. Which statement should the nurse include in this feedback? A) I realize that you had a tough time today, but it will get easier with practice. B) You cleaned the stoma well. Now you need to practice putting on the appliance. C) You seem to understand what I taught you today. What else can I help you with? D) You seem uncomfortable. Do you want your daughter to care for your ostomy?

B) You cleaned the stoma well, now you need to practice putting on the appliance. The nurse should provide both approval and room for improvement in the feedback after teaching feedback should be objective and constructive and not evaluative. Reassuring the client that they did well, The nurse should not make the client convey learning needs because the client needs to understand. The client needs to become the expert in self management and the nurse should not offer to teach the daughter instead of the client.

After teaching a client with a parasitic gastrointestinal infection a nurse assesses the client. Which statements made by the client indicate the client correctly understands the teaching select all that apply. A) Ill have my house keeper keep my toilet clean B) I must take a shower or bathe every day C) I should have my well water tested D) I will ask my sexual partner to have a stool test E) I must only eat raw vegetables from my own garden

B-C-D Parasitic infections can be transmitted to other people. The client should keep bathroom clean instead of exposing another person to the disease. Parasite are transmitted via sources and sexual practices with rectal contact. The client should test their well water and have their partners have their stool tested for parasite's. Vegetable are not associated with parasite gastrointestinal infections. The client can eat vegetable from the store or home garden as source is clean

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill. Which action should the nurse take? A) Contact the clinical pharmacist and request the medication in suspension form B) Empty the contents of the capsule into applesauce or pudding for administration C) Ask the health care provider to prescribe the medication as an enema instead D) Crush the pill carefully and administer it in applesauce or pudding

C) Ask the health care provider to prescribe the medication as an enema instead Asacol is the oral formula for mesalamine and is produced as as enteric coated pill that should not be crushed, chewed or broken. Asacol is unavailable as a suspension or elixir, if the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead with a providers order.

A nurse assesses a client who has ulcerative colitis and severe diarrhea, Which assessment should the nurse complete first? A) Inspection of oral mucosa B) Recent dietary intake C) Heart rate and rhythm D) Percussion of abdomen

C) Heart rate and rhythm Although the client with severe diarrhea may experience skin irritation and hypovolemia the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored and electrolyte replacement may be necessary. Oral mucosa inspection recent dietary intake and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm

A nurse assess a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? A) Positive Murphy's sign with rebound tenderness to palpitation B) Dull, hypoactive bowel sounds in the lower abdominal quadrants C) High pitched, rushing sounds in the right lower quadrant D) Reports of abdominal cramping that is worse at night

C) High pitched, rushing sounds in the right lower quadrant The nurse expects high pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease.

After teaching a client who has diverticulitis a nurse assesses the clients understanding. What statement by the client indicates a need for additional teaching? A) Ill ride my bike or take a long walk at least three times a week. B) I must try to include at least 25 grams of fiber in my diet every day. C) I will take a laxative nightly at bedtime to avoid becoming constipated D) I should use my legs rather than my back muscles when I lift heavy objects.

C) I will take a laxative nightly at bedtime to avoid becoming constipated Laxative are not recommended for clients with diverticulitis because they can increase pressure causing additional outpouching of the lumen. Exercise and high fiber are recommended diverticulitis because they promote regular bowel function. Using the leg muscle rather than the back lifting prevents abdominal straining.

A nurse cares for a teenage girl with a new ileostomy. The clients states I cannot go to prom with an ostomy. How should the nurse respond? A) Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance B) The pouch wont be as noticeable if you avoid broccoli and carbonated drinks prior to the prom C) Lets talk to the enterostomal therapist about options for ostomy supplies and dress styles D) You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable

C) Lets talk to the enterostomal therapist about options for ostomy supplies and dress styles The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and method to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ilestomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

After teaching a client with diverticular disease, a nurse assesses the clients understanding. Which menu selection made by the client indicated the client correctly understood the teaching? A) Roasted chicken with rice pilaf and a cup of coffee with cream B) Spaghetti with meat sauce, a fresh fruit cup and hot tea C) Garden salad with a cup of bean soup and a glass of low fat milk D) Baked fish with steamed carrots and a glass of apple juice

D) Baked fish with steamed carrots and a glass of apple juice Clients who have a diverticular disease are prescribed a low residue diet. Whole grains (Rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high fiber foods (cup of bean soup) should be avoided with a low residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low residue diet.

A nurse cares for a client who has food poisoning resulting from a clostridium botulinum. Which assessment should the nurse complete first? A) Heart rate and rhythm B) Bowel Sounds C) urinary output D) respiratory rate

D) Respiratory Rate Severe infection with C. botulinum can lead to respiratory failure so assessment of oxygen respiratory rate is high priority for clients with suspected C. botulinum infection the others may be completed after the respiratory system has been assessed