Test 3 2/22/2024 Eyes. Ears, GI System, Skin

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1.) Orthopnea and dyspnea 2.) Petechiae and ecchymosis 3.) Inguinal or umbilical hernia 4.) Poor body posture and balance 5.) Abdominal distention and tenderness

1, 2, 3, 5 Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1.) Fever 2.) Positive Cullen's sign 3.) Complaints of indigestion 4.) Palpable mass in the left upper quadrant 5.) Pain in the upper right quadrant after a fatty meal 6.) Vague lower right quadrant abdominal discomfort

1 ,3 , 5 Rationale:During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen's sign) is associated with pancreatitis.

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1 Cardiovascular disease 2 Frequent urinary tract infections 3 A history of migraine headaches 4 Frequent upper respiratory infections

1 Cardiovascular disease Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 2, 3, and 4 do not identify risk factors associated with this eye disorder.

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1.) "I will obtain adequate rest." 2.) "I will take acetaminophen if I get a headache." 3.) "I need to monitor my weight on a regular basis." 4.) "I need to include sufficient amounts of carbohydrates in my diet."

2.) "I will take acetaminophen if I get a headache." Rationale: Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care? 1.) Avoid overuse of the eyes. 2.) Decrease the amount of salt in the diet. 3.) Eye medications will need to be administered for life. 4.) Decrease fluid intake to control the intraocular pressure.

3.) Eye medications will need to be administered for life. Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of their life. Options 1, 2, and 4 are not accurate instructions.

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1.) Total loss of vision 2.) Pain in the affected eye 3.) A yellow discoloration of the sclera 4.) A sense of a curtain falling across the field of vision

4.) A sense of a curtain falling across the field of vision Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this problem. A retinal detachment is an ophthalmic emergency, and even more so if visual acuity is still normal.

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription would the nurse anticipate? 1.) Allowing bathroom privileges only 2.) Elevating the head of the bed to 45 degrees 3.) Wearing dark glasses to read or watch television 4.) Placing an eye patch over the client's affected eye

4.) Placing an eye patch over the client's affected eye Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client's position is prescribed by the primary health care provider; normally, the prescription is to lie flat.

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food would the nurse instruct the client to avoid? 1.) Bagel 2.) Watermelon 3.) Lentil soup 4.) Salsa and corn chips

4.) Salsa and corn chips Rationale: The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? 1.) Colectomy 2.) Appendectomy 3.) Ascending colostomy 4.) Small bowel resection

4.) Small bowel resection Rationale :The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients.

A low-fiber diet may be prescribed, especially during periods of Crohn's disease exacerbations. True or False

True

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1"Does the pain in your stomach radiate to your back?" 2"Does the pain in your lower abdomen radiate to your hip?" 3"Does the pain in your lower abdomen radiate to your groin?" 4"Does the pain in your stomach radiate to your lower middle abdomen?"

1"Does the pain in your stomach radiate to your back?" Rationale:The pain that is associated with acute pancreatitis is often severe, is located in the epigastric region, and radiates to the back. The remaining options are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions would be included in the care plan for this client? Select all that apply. 1.) Monitor daily weight. 2.) Measure abdominal girth. 3.) Monitor respiratory status. 4.) Place the client in a supine position. 5.) Assist the client with care as needed.

1, 2, 3, 5 Rationale: Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client would be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1.) Maintain NPO status. 2.) Encourage coughing and deep breathing. 3.) Give small, frequent high-calorie feedings. 4.) Maintain the client in a supine and flat position. 5.) Give hydromorphone intravenously as prescribed for pain. 6.) Maintain intravenous fluids at 10 mL/hour to keep the vein open.

1, 2, 6 Rationale:The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

The nurse is caring for a hospitalized client with pancreatitis. Which findings would the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1.) Elevated lipase level 2.) Elevated lactase level 3.) Elevated trypsin level 4.) Elevated amylase level 5.) Elevated sucrase level

1, 3, 4 Rationale: Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures would the nurse include in the plan? Select all that apply. 1.) Avoid activities that require bending over. 2.) Contact the surgeon if eye scratchiness occurs. 3.) Take acetaminophen for minor eye discomfort. 4.) Expect episodes of sudden severe pain in the eye. 5.) Place an eye shield on the surgical eye at bedtime. 6.) Contact the surgeon if a decrease in visual acuity occurs.

1, 3, 5, 6 Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye; these are usually relieved by mild analgesics. If the eye pain becomes severe, the client needs to notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.

The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which actions would the nurse take that will result in proper tube insertion and promote client relaxation? Select all that apply. 1.) Pull the tube back slightly. 2.) Instruct the client to breathe slowly. 3.) Assist the client to take sips of water. 4.) Continue to slowly advance the tube to the desired distance. 5.) Check the back of the pharynx using a tongue blade and flashlight.

1,2, 3, 5 Rationale :As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse would check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes.

A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? 1.) "I eat at least 3 large meals each day." 2.) "I eat while lying in a semirecumbent position." 3.) "I have eliminated taking liquids with my meals." 4.) "I eat a high-protein, low- to moderate-carbohydrate diet."

1.) "I eat at least 3 large meals each day." Rationale:Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals.

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? 1.) "I need to limit my intake of dietary protein." 2.) "I need to drink plenty, at least 8 to 10 cups daily." 3.) "I need to eat regular meals and chew my food well." 4.) "I will take the prescribed medications because they will regulate my bowel patterns."

1.) "I need to limit my intake of dietary protein." Rationale:IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. A high-calorie, high-vitamin, high-protein and low-residue diet manages the problem. However, the diet is highly individualized, depending on physician preference

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1.) "I need to sleep on my left side." 2.) "I would sleep on my right side." 3.) "I would sleep with my head flat." 4.) "I would not wear my glasses at any time."

1.) "I need to sleep on my left side." Rationale:After cataract surgery, the client would not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also needs to be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? 1.) "The hearing aid would not be worn if an ear infection is present." 2.) "The ear mold for the hearing aid needs to be washed with mild soap and water once a month." 3.) "The hearing aid needs to be removed from the ear at the end of the day and then turned off after removal." 4.) "The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."

1.) "The hearing aid would not be worn if an ear infection is present." Rationale: The client needs to be instructed that the hearing aid would not be worn if an ear infection is present. The client needs to wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client needs to be instructed to turn off the hearing aid before removing it from the ear to prevent any squealing feedback. The hearing aid needs to be turned off when not in use, and the client would keep extra batteries on hand at all times.

The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse would instruct the client to take which measure? 1.) Avoid air travel. 2.) Shower daily to prevent infection. 3.) Resume all normal activities in 1 week. 4.) Drink liquids through a straw for the next 2 to 3 weeks.

1.) Avoid air travel. Rationale: After ear surgery, the client needs to be instructed to avoid air travel, excessive coughing, and drinking through a straw for 2 to 3 weeks. In addition, the client needs to avoid straining when having a bowel movement and would avoid washing the hair, getting the head wet, or showering for 1 week. The client also needs to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate? 1.) Change the dressing. 2.) Continue to monitor the drainage. 3.) Notify the primary health care provider (PHCP). 4.) Use a pen to circle the amount of drainage on the dressing.

1.) Change the dressing. Rationale: Serosanguinous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and would be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing. The PHCP does not need to be notified.

The nurse is caring for a client with gallbladder disease who is experiencing nutrition problems due to biliary obstruction. The nurse understands that obstruction of which passage is related to the client's condition? 1.) Cystic duct 2.) Liver canaliculi 3.) Common bile duct 4.) Right hepatic duct

1.) Cystic duct Rationale: The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the duodenum by way of the common bile duct.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)? 1.) Dark red drainage 2.) Dark brown drainage 3.) Green-tinged drainage 4.) Light yellowish-brown drainage

1.) Dark red drainage Rationale:For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The PHCP needs to be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

The nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation? 1.) Dizziness 2.) Photophobia 3.) Hemianopsia 4.) Blurred vision

1.) Dizziness Rationale:Ménière's disease is a disorder of the inner ear characterized by dizziness and loss of balance. This requires the addition of safety to the care plan. The clinical manifestations in the remaining options are not found with Ménière's disease.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the primary health care provider? 1.) Elevated serum bilirubin level 2.) Below-normal hemoglobin concentration 3.) Elevated blood urea nitrogen (BUN) level 4.) Elevated erythrocyte sedimentation rate (ESR)

1.) Elevated serum bilirubin level Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence? 1.) Inability to pass flatus 2.) Loss of anal sphincter control 3.) Severe, constant pain with rapid onset 4.) Firm, nontender mass palpable at the lower right costal margin

1.) Inability to pass flatus Rationale :An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? 1.) Inability to pass flatus 2.) Loss of anal sphincter control 3.) Severe, constant pain with rapid onset 4.) Firm, nontender mass palpable at the lower right costal margin

1.) Inability to pass flatus Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of anal sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, palpable mass at the right costal margin describes the physical finding of liver enlargement, which is usually associated with cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, this is not a sign of paralytic ileus or intestinal obstruction.

The nurse is caring for a client with common bile duct obstruction. The nurse would anticipate that the primary health care provider (PHCP) will prescribe which diet for this client? 1.) Low fat 2.) High protein 3.) High carbohydrate 4.) Low in water-soluble vitamins

1.) Low fat Rationale: Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. The diets listed in the remaining options are incorrect.

The nurse is giving dietary instructions to a client who has a new colostomy created to treat a bowel obstruction. The nurse would encourage the client to eat foods representing which diet for the first few weeks postoperatively? 1.) Low fiber 2.) Low calorie 3.) High protein 4.) High carbohydrate

1.) Low fiber Rationale:For the first few weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client would eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1.) Malaise 2.) Dark stools 3.) Weight gain 4.) Left upper quadrant discomfort

1.) Malaise Rationale:Hepatitis causes GI symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1.) Notify the surgeon. 2.) Administer the prescribed pain medication. 3.) Call and ask the operating room team to perform surgery as soon as possible. 4.) Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

1.) Notify the surgeon. Rationale:On the basis of the signs and symptoms presented in the question, the nurse would suspect peritonitis and notify the surgeon.

A client has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? 1.) Remove fluids from the meal tray. 2.) Give the client 2 large meals per day. 3.) Ask the client to sit up for 1 hour after eating. 4.) Provide a diet high in simple carbohydrate foods.

1.) Remove fluids from the meal tray. Rationale:Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low-Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding food sources high in simple carbohydrates (sugar, corn syrup, juice concentrate). Antispasmodic medications also are prescribed as needed to delay gastric emptying.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1.) Sweating and pallor 2.) Bradycardia and indigestion 3.) Double vision and chest pain 4.) Abdominal cramping and pain

1.) Sweating and pallor Rationale:Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information would the nurse include in the teaching plan? 1.) Use 500 to 1000 mL of warm tap water. 2.) Suspend the irrigant 36 inches above the stoma. 3.) Insert the irrigation cone ½ inch into the stoma. 4.) If cramping occurs, open the irrigation clamp farther.

1.) Use 500 to 1000 mL of warm tap water. Rationale:The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but would never be forced. If cramping occurs, the client would decrease the flow rate of the irrigant as needed by closing the irrigation clamp. This practice is not common because of odor-proof pouches.

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions would the nurse take when performing the irrigation? Select all that apply. 1.) Apply some force when instilling the irrigation solution. 2.) Position the client with the affected side down after the irrigation. 3.) Warm the irrigating solution to a temperature that is close to body temperature. 4.) Position the client to turn the head so that the ear to be irrigated is facing upward. 5.) Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.

2, 3, 5 Rationale:During the irrigation, the client sits upright with a towel on the shoulder to capture water that drains from the ear. The ear to be irrigated is tilted to the side because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution would be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client would lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.

The student nurse is working with a registered nurse (RN) in the clinic. The RN is educating the student nurse on dysfunction in the area of the semicircular canals of the ear. Which statement by the student nurse indicates that the teaching has been effective? 1.) "Tinnitus is common." 2.) "Disturbance in balance occurs." 3.) "Conduction hearing loss often happens." 4.) "Sensorineural hearing loss is not unusual."

2.) "Disturbance in balance occurs." Rationale:The semicircular canals function to aid the client's sense of balance. These canals do not relate to hearing function or the presence of tinnitus.

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1.) "I would avoid drinking alcohol." 2.) "I can go back to work right away." 3.) "My partner needs to get the vaccine." 4.) "A condom would be used for sexual intercourse."

2.) "I can go back to work right away." Rationale:To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol needs to be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client would not return to work right away.

The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? 1.) Strict bed rest 2.) A myringotomy 3.) A mastoidectomy 4.) Diphenhydramine

2.) A myringotomy Rationale:A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear and may be necessary to treat acute otitis media. Strict bed rest is not necessary, although activity may be restricted. Additionally, bed rest would not assist in reducing pressure or allowing fluid to drain. In some recurrent and persistent cases, the mastoid bone is removed or partially removed for chronic otitis media. Diphenhydramine is an antihistamine with antiemetic properties.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding would the nurse interpret as a sign or symptom of portal hypertension? 1.) Flat neck veins 2.) Abdominal distention 3.) Hemoglobin of 14.2 g/dL (142 mmol/L) 4.) Platelet count of 600,000 mm3 (600 × 109/L)

2.) Abdominal distention Rationale :With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).

A client with Ménière's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo? 1.) Increase sodium in the diet. 2.) Avoid sudden head movements. 3.) Lie still and watch the television. 4.) Increase fluid intake to 3000 mL a day.

2.) Avoid sudden head movements. Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful? 1.) Fresh fruit 2.) Brown gravy 3.) Fresh vegetables 4.) Poultry without skin

2.) Brown gravy Rationale: The client with cholecystitis would decrease overall intake of dietary fat. Foods that need to be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.

The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1.) Client report of blurred vision 2.) Client report of "tunnel vision" 3.) Client report of ocular erythema 4.) Client report of halos around lights

2.) Client report of "tunnel vision" Rationale: POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.

The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? 1.) Rice 2.) Corn 3.) Broiled chicken 4.) Cream of wheat

2.) Corn Rationale The client with irritable bowel needs to take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. Corn is high in fiber but can be very irritating to the intestines and would be avoided. The food items in the other options are acceptable to eat.

A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention would the nurse implement initially? 1.) Irrigation of the ear 2.) Instillation of mineral oil 3.) Instillation of antibiotic eardrops 4.) Instillation of corticosteroid ointment

2.) Instillation of mineral oil Rationale Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction. Antibiotic eardrops and corticosteroid ointment are not initial nursing actions.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action would the nurse implement based on this finding? 1.) Provide the client with materials on legal blindness. 2.) Instruct the client about the need glasses when driving. 3.) Inform the client of where a white cane with a red tip can be purchased. 4.) Inform the client that it is best to sit near the back of the room when attending conferences and lectures.

2.) Instruct the client about the need glasses when driving. Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client would be instructed to sit in the front of the room for conferences and lectures to aid in visualization. This is not considered to be legal blindness.

The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1.) Leukopenia with a shift to the left 2.) Leukocytosis with a shift to the left 3.) Leukopenia with a shift to the right 4.) Leukocytosis with a shift to the right

2.) Leukocytosis with a shift to the left Rationale:Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appendicitis.

The nurse is caring for a client with a small bowel obstruction who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse would anticipate a primary health care provider prescription for which type of suction? 1.) Low and continuous 2.) Low and intermittent 3.) High and intermittent 4.) High and continuous

2.) Low and intermittent Rationale: Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction needs to be set on low pressure and intermittent suction control.

The nurse is reviewing the primary health care provider's prescriptions for a client with Ménière's disease. Which diet would most likely be prescribed for the client? 1.) Low-fat diet 2.) Low-sodium diet 3.) Low-cholesterol diet 4.) Low-carbohydrate diet

2.) Low-sodium diet Rationale:Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for a client with Ménière's disease. The diets in the remaining options are not specific to the client with Ménière's disease.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1.) Sitting up 2.) Lying flat 3.) Leaning forward 4.) Drawing the legs to the chest

2.) Lying flat Rationale: The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids? 1.) Nuts 2.) Meats 3.) Cereals 4.) Vegetables

2.) Meats Rationale: Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate? 1.) Encourage foods that are high in protein. 2.) Monitor for fluid and electrolyte imbalance. 3.) Explain that high-fat diets usually are better tolerated. 4.) Explain that most daily calories need to be consumed in the evening hours.

2.) Monitor for fluid and electrolyte imbalance. Rationale:If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories need to be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients would select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What would be the nurse's initial action? 1.) Apply normal saline drops. 2.) Note the time of day the test was done. 3.) Contact the primary health care provider (PHCP). 4.) Instruct the client to sleep with the head of the bed flat.

2.) Note the time of day the test was done. Rationale:Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed.

The nurse is assessing a client with cirrhosis for signs and symptoms of low albumin. Which sign or symptom would the nurse expect to note? 1.) Weight loss 2.) Peripheral edema 3.) Capillary refill of 5 seconds 4.) Bleeding from previous puncture sites

2.) Peripheral edema Rationale: Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1.) Fatigue on exertion 2.) Presence of asterixis 3.) Elevated pulse rate 4.) Decreased serum ammonia levels

2.) Presence of asterixis Rationale: Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted. Fatigue on exertion and elevated pulse rate are not specific assessment findings in hepatic encephalopathy.

The nurse is providing care for a client with a recent transverse colostomy created to resolve a bowel obstruction. Which observation requires immediate notification of the primary health care provider? 1.) Stoma is beefy red and shiny 2.) Purple discoloration of the stoma 3.) Skin excoriation around the stoma 4.) Semi-formed stool noted in the ostomy pouch

2.) Purple discoloration of the stoma Rationale:Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.

The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? 1.) Fatigue 2.) Tinnitus 3.) Headache 4.) Insomnia

2.) Tinnitus Rationale, Strategy, Tip Rationale:Ménière's disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus. Fatigue, headaches, and insomnia are not associated with this disorder.

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? 1.) Pruritus 2.) Tinnitus 3.) Hearing loss 4.) Burning in the ear

2.) Tinnitus Rationale: Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear.

The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder? 1.) Weight gain 2.) Use of alcohol 3.) Exposure to occupational chemicals 4.) Abdominal pain relieved with food or antacids

2.) Use of alcohol Rationale: Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.

The nurse is caring for a client who had a subtotal gastrectomy. The nurse would assess the client for which signs and symptoms of dumping syndrome? 1.) Diarrhea, chills, and hiccups 2.) Weakness, diaphoresis, and diarrhea 3.) Fever, constipation, and rectal bleeding 4.) Abdominal pain, elevated temperature, and weakness

2.) Weakness, diaphoresis, and diarrhea Rationale: Dumping syndrome occurs after gastric surgery because food is not held long enough in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular and gastrointestinal symptoms. Signs and symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.

The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which client statement indicates that the educational session was effective? 1"I need to be sure to eat at least 1 cucumber every day." 2"I will need to increase my egg intake and try to eat ½ to 1 egg per day." 3"Beet greens, parsley, or yogurt will help to control the colostomy odor." 4"Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day."

3"Beet greens, parsley, or yogurt will help to control the colostomy odor." Rationale:The client needs to be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and needs to be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and need to be avoided or limited by the client.

The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? 1.) "I plan to eat four to six small meals a day." 2.) "I need to sleep in the right side-lying position." 3.) "I plan to have a snack 1 hour before going to bed." 4.) "I will stop having a glass of wine each evening with dinner."

3.) "I plan to have a snack 1 hour before going to bed." Rationale:The control of GERD involves lifestyle changes to promote health and control reflux. These lifestyle changes include eating four to six small meals a day; avoiding alcohol and smoking; sleeping in the right side-lying position to promote oxygenation; and frequent swallowing to clear the esophagus; and avoiding eating at least 3 hours before going to bed because reflux episodes are most damaging at night.

The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period? 1.) "When I can tolerate food without vomiting." 2.) "When my gastrointestinal system is healed enough." 3.) "When my bowels begin to function again, and I begin to pass gas." 4.) "When my primary health care provider says the tube can come out."

3.) "When my bowels begin to function again, and I begin to pass gas." Rationale: NG tubes are discontinued when normal function returns to the gastrointestinal (GI) tract. Food would not be administered unless bowel function returns. The tube will be removed before GI healing. Although the primary health care provider (PHCP) determines when the NG tube will be removed, it does not determine effectiveness of teaching and the need for the NG tube.

The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? 1.) A client with bilateral profound hearing loss 2.) A client who communicates primarily by speech 3.) A client who became deaf before learning to speak 4.) A client who received no benefit from conventional hearing aids

3.) A client who became deaf before learning to speak Rationale:Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use of speech as the primary mode of communication, lack of benefit from conventional hearing aids, evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure.

A primary health care provider (PHCP) prescribes a Salem sump tube for gastrointestinal intubation. Which item would the nurse obtain from the supply room? 1.) A Dobbhoff weighted tube 2.) A Sengstaken-Blakemore tube 3.) A tube with a large lumen and an air vent 4.) A tube with a single lumen that connects to suction

3.) A tube with a large lumen and an air vent Rationale:A tube with a large lumen and an air vent is a Salem sump tube. A Dobbhoff weighted tube is a type of feeding tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A tube with a single lumen is called a Levin tube.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse would assess the client for a history of chronic use of which medication? 1.) Ibuprofen 2.) Ranitidine 3.) Acetaminophen 4.) Acetylsalicylic acid (Aspirin)

3.) Acetaminophen Rationale: Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents would be investigated whenever a client presents with signs and symptoms compatible with liver disease (i.e., ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the remaining options.

A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse would tell the client that which medication is acceptable to take? 1.) Ibuprofen 2.) Indomethacin 3.) Acetaminophen 4.) Naproxen sodium

3.) Acetaminophen Rationale: Analgesics such as acetaminophen are unlikely to cause epigastric distress. Ibuprofen, indomethacin, and naproxen sodium are nonsteroidal anti-inflammatory medications (NSAIDs) and are irritating to the gastrointestinal tract, so they need to be avoided in clients with gastritis.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse would question which primary health care provider (PHCP) prescription documented in the client's medical record? 1.) Apply a cold pack to the abdomen. 2.) Maintain nothing by mouth (NPO) status. 3.) Administer 30 mL of milk of magnesia (MOM). 4.) Initiate an intravenous (IV) line for the administration of IV fluids.

3.) Administer 30 mL of milk of magnesia (MOM). Rationale:Appendicitis would be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain. Appendicitis is suspected, and appropriate laboratory tests are performed. The emergency department nurse reviews the test results and notes that the client's white blood cell (WBC) count is elevated. The nurse also reviews the prescriptions from the primary health care provider (PHCP). The nurse would contact the PHCP to question which order if noted in the client's record? 1.) Maintain a semi-Fowler's position. 2.) Maintain on NPO (nothing by mouth) status. 3.) Apply a heating pad to the lower abdomen for comfort. 4.) Initiate an intravenous (IV) line with the administration of IV fluids.

3.) Apply a heating pad to the lower abdomen for comfort. Rationale: Appendicitis would be suspected in a client with an elevated WBC count who is complaining of acute right lower quadrant abdominal pain. A semi-Fowler's position is maintained for comfort. The client would be on NPO status and given IV fluids in preparation for possible surgery. Heat would never be applied to the abdomen because this may increase circulation to the appendix, potentially leading to increased inflammation and perforation.

The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate? 1.) Document the finding. 2.) Reinforce the dressing. 3.) Contact the surgeon. 4.) Mark the site and continue to monitor.

3.) Contact the surgeon. Rationale:After enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the surgeon needs to be notified immediately. The remaining options are not appropriate nursing actions for this client.

The nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is 250 mL at 0800 and 300 mL at 0900. The nurse determines that the client is experiencing which complication? 1.) Air in the stomach 2.) Too slow an infusion rate 3.) Delayed gastric emptying 4.) Early signs of peptic ulcer

3.) Delayed gastric emptying Rationale:If the gastric residual is greater than 200 mL for 2 consecutive hours, the client may be experiencing delayed gastric emptying. If this occurs, the feeding is stopped, and the primary health care provider needs to be notified. The nurse would assess whether abdominal girth is enlarged and would auscultate bowel sounds to rule out intestinal obstruction.

The nurse is caring for a client with pancreatitis. Which finding would the nurse expect to note when reviewing the client's laboratory results? 1.) Elevated level of pepsin 2.) Elevated level of lactase 3.) Elevated level of amylase 4.) Elevated level of enterokinase

3.) Elevated level of amylase Rationale: The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.

The nurse is preparing to administer an intermittent enteral feeding through a nasogastric (NG) tube. Which priority assessment would the nurse perform? 1.) Observe for digestion of formula. 2.) Assess fluid and electrolyte status. 3.) Evaluate absorption of the last feeding. 4.) Evaluate percussion tone of the stomach.

3.) Evaluate absorption of the last feeding. Rationale: All stomach contents are aspirated and measured before a tube feeding is administered. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of an enteral feeding to a full stomach could result in overdistention, predisposing the client to regurgitation and possible aspiration. The remaining options do not relate to the purpose of assessing residual.

The nurse is caring for a client admitted with severe weight loss due to dieting. Based on the data provided, the nurse plans care knowing that which condition is likely occurring in this client? 1.) Lactic acidosis 2.) Glycogenolysis 3.) Gluconeogenesis 4.) Glucose metabolism

3.) Gluconeogenesis Rationale: Gluconeogenesis is the production of glucose for energy from protein and fat stores in the body. This can occur with extreme dieting and also with diabetes mellitus. Glycogenolysis is the production of glucose from glycogen stores in the liver. Lactic acidosis occurs with excess production of lactic acid resulting from anaerobic metabolism. The body normally burns glucose for energy.

The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse would assess the stool for which characteristic that is expected with this disease? 1.) Blood in the stool 2.) Chalky gray stool 3.) Loose, watery stool 4.) Dark brown pellet-like stools

3.) Loose, watery stool Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity. Options 1, 2, and 4 are not characteristics of the stool in Crohn's disease.

The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? 1.) Maintain a supine position. 2.) Change the ear dressing daily. 3.) Monitor for signs of facial nerve injury. 4.) Position the client on the affected side to promote drainage.

3.) Monitor for signs of facial nerve injury. Rationale:After mastoidectomy, the nurse would assess for signs of facial nerve injury (cranial nerve VII), such as facial drooping. The nurse needs to monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also would monitor for signs of pain, dizziness, or nausea.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which sign(s)/symptom(s) of duodenal ulcer? 1.) Weight loss 2.) Nausea and vomiting 3.) Pain relieved by food intake 4.) Pain radiating down the right arm

3.) Pain relieved by food intake A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1.) Speak loudly. 2.) Speak frequently. 3.) Speak at a normal volume. 4.) Speak directly into the impaired ear.

3.) Speak at a normal volume. Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse would talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse would express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse would avoid talking directly into the impaired ear.

The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? 1.) The client reports some pain before meals. 2.) The client frequently is awakened at 2 a.m. with heartburn. 3.) The client has eliminated any irritating foods from the diet. 4.) The client's pain is minimal with histamine H2-receptor antagonists.

3.) The client has eliminated any irritating foods from the diet. Rationale: Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self-reporting of absence of pain with medication, and an ability to sleep through the night without pain.

A client with gastritis experiencing chronic gastric hypersecretion is scheduled for surgery. The nurse teaches the client that the procedure will lessen the stomach's production of acid by altering which structure? 1.) Portal vein 2.) Celiac artery 3.) Vagus nerve 4.) Pyloric valve

3.) Vagus nerve Rationale: Vagotomy is a procedure that can reduce innervation to the stomach, thereby reducing the production of gastric acid. The portal vein drains venous blood from the stomach. The celiac artery brings arterial blood to the stomach. The pyloric valve separates the stomach from the duodenum. The pyloric valve may undergo surgical repair if it becomes stenosed; this procedure is known as pyloroplasty.

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1.) Diarrhea 2.) Black, tarry stools 3.) Hyperactive bowel sounds 4.) Gray-blue color at the flank 5.) Abdominal guarding and tenderness 6.) Left upper quadrant pain with radiation to the back

4, 5, 6 Rationale:Grayish-blue discoloration at the flank is known as Grey Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding would the nurse expect to observe? 1.) A pink-colored tympanic membrane 2.) A pearly colored tympanic membrane 3.) A transparent and clear tympanic membrane 4.) A red, dull, thick, and immobile tympanic membrane

4- A red, dull, thick, and immobile tympanic membrane Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. A normal tympanic membrane is pearly gray, intact, with a positive cone of light reflex.

The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of a gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? 1.) "It's due to insufficient production of vitamin B12 in the colon." 2.) "Increased production of intrinsic factor in the stomach leads to this type of anemia." 3.) "Overproduction of vitamin B12 in the large intestine can result in pernicious anemia." 4.) "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."

4.) "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine." Rationale :Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not produced or absorbed in the large intestine.

The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? 1.) "I need to restrict my carbohydrate intake." 2.) "I need to drink at least 3 L of fluid per day." 3.) "I need to maintain a low-fat and low-cholesterol diet." 4.) "I need to be sure to consume foods that are low in sodium."

4.) "I need to be sure to consume foods that are low in sodium." Rationale:Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client would be instructed to consume a low-sodium diet and restrict fluids as prescribed

The client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube attached to continuous gastric suction. The nurse determines that teaching has been effective if the client makes which statement? 1.) "It will help to provide me with nourishment." 2.) "It will help to relieve the congestion from excess mucus." 3.) "It is used to remove gastric contents for laboratory testing." 4.) "It will help to remove gas and fluids from my stomach and intestine."

4.) "It will help to remove gas and fluids from my stomach and intestine." Rationale: Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction.

The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? 1.) "It's a loss of vision associated with aging." 2.) "A loss of balance occurs with presbycusis." 3.) "Presbycusis is a conductive hearing loss that occurs with aging." 4.) "It's a sensorineural hearing loss that occurs with the aging process."

4.) "It's a sensorineural hearing loss that occurs with the aging process." Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. The statements in the remaining options are incorrect statements about this condition.

A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication would the nurse look for during the client's post procedure assessment? 1.) Bradycardia 2.) Nausea and vomiting 3.) Numbness in the legs 4.) A rigid, board-like abdomen

4.) A rigid, board-like abdomen Rationale: The client with a large, deep duodenal ulcer is at risk for perforation of the ulcer. If this occurs, the client will experience sudden, sharp, intolerable, and severe pain beginning in the midepigastric area and spreading over the abdomen, which then becomes rigid and boardlike. Tachycardia, not bradycardia, may occur as hypovolemic shock develops. Nausea and vomiting may not occur if the pyloric sphincter is intact. Numbness in the legs is not an associated finding.

The clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which finding would the nurse expect to observe if the eardrum is perforated? 1.) A red and bulging eardrum 2.) Dense white patches on the eardrum 3.) A colony of black dots on the eardrum 4.) A round or oval darkened area on the eardrum

4.) A round or oval darkened area on the eardrum Rationale:A round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. A red and bulging eardrum is indicative of acute purulent otitis media. Dense white patches are seen on the eardrum of a client with sequelae of repeated ear infections. A colony of black dots on the eardrum suggests a yeast or fungal infection.

The nurse is caring for a client with acute respiratory distress syndrome on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse would take which action? 1.) Document the findings. 2.) Reassess the pH in 4 hours. 3.) Instill 30 mL of sterile water. 4.) Administer a dose of a prescribed antacid.

4.) Administer a dose of a prescribed antacid. Rationale:The client on a mechanical ventilator who has a nasogastric tube in place needs to have the gastric pH monitored at the beginning of each shift or at least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) would be treated with prescribed antacids. If there is no prescription for the antacid, the primary health care provider would be notified. Documentation of the findings needs to be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages of cataract formation? 1.) Diplopia 2.) Eye pain 3.) Floating spots 4.) Blurred vision

4.) Blurred vision Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1.) Checking for normal serum electrolyte levels 2.) Checking for normal pH of the gastric aspirate 3.) Checking for proper nasogastric tube placement 4.) Checking for the presence of bowel sounds in all four quadrants

4.) Checking for the presence of bowel sounds in all four quadrants Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

The nurse is caring for a client who has just returned from the operating room after colectomy to remove a bowel tumor and the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment? 1.) Apply ice to the stoma site. 2.) Apply pressure to the stoma site. 3.) Notify the primary health care provider. 4.) Document the amount and characteristics of the drainage.

4.) Document the amount and characteristics of the drainage. Rationale :During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Applying ice or pressure to the stoma site are inappropriate actions. Notifying the PHCP is unnecessary because this is an expected finding.

A client has just had surgery to create an ileostomy for treatment of a bowel obstruction. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery? 1.) Folate deficiency 2.) Malabsorption of fat 3.) Intestinal obstruction 4.) Fluid and electrolyte imbalance

4.) Fluid and electrolyte imbalance Rationale:A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? 1.) Carrots and ranch dip 2.) Whole-grain cereal and milk 3.) A cup of popcorn and a cola drink 4.) Gelatin and a graham cracker

4.) Gelatin and a graham cracker Rationale:The diet for the client with acute ulcerative colitis needs to be low fiber (low residue). The nurse would avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also needs to avoid caffeine, pepper, and alcohol.

A client with a diagnosis of stomach ulcer from gastric hyperacidity asks the nurse why the acid has not caused an ulcer in the small intestine as well. The nurse responds that the pH of intestinal contents is raised by bicarbonate, which is present in which area of the body? 1.) Bile 2.) Parietal cells 3.) Liver enzymes 4.) Pancreatic juice

4.) Pancreatic juice Rationale: Pancreatic juice is rich in bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. Bile, parietal cells, and liver enzymes are not substances rich in bicarbonate and are incorrect.

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action would the nurse take? 1.) Speak loudly, but mumble or slur the words. 2.) Speak loudly and clearly while facing the client. 3.) Speak loudly and directly into the client's affected ear. 4.) Speak at normal tone and pitch, slowly and clearly.

4.) Speak at normal tone and pitch, slowly and clearly. Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse would speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.

The nurse would anticipate that the primary health care provider (PHCP) will prescribe which treatment for a client with pernicious anemia? 1.) Oral iron tablets 2.) Blood transfusions 3.) Gastric tube feedings 4.) Vitamin B12 injections

4.) Vitamin B12 injections Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption.

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? 1.) Hypercalcemia 2.) Hypernatremia 3.) Frothy, fatty stools 4.) Decreased hemoglobin

4.)_ Decreased hemoglobin Rationale:Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).

:There are three stages associated with viral hepatitis. The first (preicteric) stage includes_____________________ symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as ________________bilirubin levels, _____________ urine, and _____________-colored stools. The third (posticteric) stage, also known as the recovery stage, occurs when the jaundice decreases and the colors of the urine and stool return to normal.

Flu-like Elevated Dark/Tea-colored Clay