HESI REVIEW
A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? 1 Computed tomography (CT) scan 2 Gastroscopy 3 Colonoscopy 4 Barium enema
1 Computed tomography (CT) scan A CT scan with contrast is the test of choice for diverticulitis because it effectively reflects the involved colon. An endoscopy assesses the upper, not lower, gastrointestinal tract. Colonoscopy is contraindicated because of the possibility of perforation and peritonitis. Barium enema is contraindicated because of the possibility of perforation and peritonitis.
A nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indicators associated with these conditions? (Select all that apply.) 1 Ecchymosis 2 Yellow sclera 3 Dark brown stool 4 Straw-colored urine 5 Pain in right upper quadrant
1 Ecchymosis 2 Yellow sclera 5 Pain in right upper quadrant Inadequate bile flow interferes with vitamin K absorption, contributing to ecchymosis, hematuria, and other bleeding. Yellow sclera results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into the blood. The bilirubin is carried to all body regions, including the skin and mucous membranes. Pain in the right upper quadrant occurs especially after eating foods high in fat and is characteristic of acute cholecystitis and biliary colic. With obstructive jaundice the stool is clay-colored, not dark brown; the presence of bile causes stool to be brown. When bile levels in the bloodstream are high, as in obstructive jaundice, there is bile in the urine, causing it to have a dark color.
A client is diagnosed with Crohn's disease, and parenteral vitamins are prescribed. The client asks why the vitamins have to be given intravenously (IV) rather than by mouth. What rationales for this route should the nurse include in a response to the question? (Select all that apply.) 1 More rapid action results. 2 They are ineffective orally. 3 They decrease colon irritability. 4 Intestinal absorption may be inadequate. 5 Allergic responses are less likely to occur.
1 More rapid action results. 2 They are ineffective orally. 4 Intestinal absorption may be inadequate. Absorption through the gastrointestinal (GI) tract is impaired and parenteral administration goes directly into the intravascular compartment. Disease of the GI tract hampers absorption. Because the mucosa of the intestinal tract is damaged, its ability to absorb vitamins taken orally is greatly impaired. IV vitamins do not decrease colonic irritability. Route of administration does not affect allergic response.
A client receiving chemotherapy takes a steroid daily. The client has a white blood cell count of 12,000/mm3 and a red blood cell count of 4.5 million/mm3. What is the priority instruction that the nurse should teach the client? 1 Omit the daily dose of prednisone 2 Avoid large crowds and persons with infections 3 Shave with an electric shaver rather than a safety razor 4 Increase the intake of high protein foods and red meats
2 Avoid large crowds and persons with infections Moderate leukopenia increases the risk of infection; the client should be taught protective measures. Leukopenia is a side effect of cyclophosphamide (Cytoxan), not prednisone. The platelet count has not been provided, so bleeding precautions are not indicated. Increasing the intake of high protein foods and red meat are measures to correct anemia; protection from infection takes priority.
Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia? (Select all that apply.) 1 Irritability 2 Dysrhythmias 3 Muscle weakness 4 Abdominal cramps 5 Tingling of the fingertips
2 Dysrhythmias 3 Muscle weakness Dysrhythmias are a sign of potassium depletion in cardiac muscle. Other cardiovascular effects include irregular, rapid, weak pulse, decreased blood pressure, flattened and inverted T waves, prominent U waves, depressed ST segments, peaked P waves, and prolonged QT intervals. Muscle weakness is a symptom of potassium depletion in skeletal muscles; potassium facilitates the conduction of nerve impulses and muscle activity. Irritability, as a result of heightened neuromuscular activity, is a sign of hyperkalemia. Abdominal cramps, as a result of heightened neuromuscular activity, are symptoms of hyperkalemia. Tingling of the fingertips, as a result of a lowered threshold of excitation of peripheral sensory nerve fibers, is a symptom of hypocalcemia.
During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement? 1 An understanding of safer sex 2 An ability to assume self-responsibility 3 Ignorance related to correct condom use 4 Ignorance concerning the transmission of human immunodeficiency virus (HIV)
3 Ignorance related to correct condom use Vaseline (petroleum jelly) breaks down condom integrity and will increase the risk for condom failure. Using Vaseline instead of a water-soluble lubricant shows a lack of knowledge about condom use, a form of safer sex. Although the person is attempting to be responsible, there is a lack of knowledge and the behavior is unsafe. Condom use shows the client has some understanding about the transmission of HIV.
A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client? 1 Assess frequently for nasal drying. 2 Keep the mask tight against the face. 3 Monitor oxygen saturation levels when eating. 4 Set the oxygen flow at the highest setting possible.
3 Monitor oxygen saturation levels when eating. Because the mask cannot be worn when eating, the client may become hypoxic. A nasal cannula may be needed to deliver oxygen while the client is eating. Nasal drying usually is not a problem with the use of a Venturi mask. Nasal drying occurs more frequently when a nasal cannula is used. Too tight a fit is uncomfortable and may cause damage to the skin. The mask should fit snugly, but not be too tight. The oxygen should be set at the level prescribed by the health care provider.
What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection? 1 Originated primarily from an exogenous source. 2 Is associated with a drug resistant microorganism. 3 Occurred in conjunction with treatment for an illness. 4 Still has the infection despite completing the prescribed therapy.
3 Occurred in conjunction with treatment for an illness. Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a drug-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a drug-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.
When taking the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS), the nurse must: 1 Don clean gloves 2 Use barrier techniques 3 Put on a mask and gown 4 Wash the hands thoroughly
4 Wash the hands thoroughly Because this procedure does not involve contact with blood or secretions, additional protection to washing the hands thoroughly is not indicated. Donning clean gloves and using barrier techniques are necessary only when there is risk of contact with blood or body fluid. A mask and gown are indicated only if there is a danger of secretions or blood splattering on the nurse (for example, during suctioning).
A nurse advises a client receiving furosemide (Lasix) to increase potassium intake. Which fruit should the nurse encourage the client to eat? (Select all that apply.) 1 Prune 2 Apple 3 Banana 4 Pineapple 5 Tangerine
1 Prune 3 Banana Prunes contain 262 mg of potassium per 100 grams, which is more than the other choices. Bananas contain 396 mg of potassium per 100 grams. Apples contain 110 mg of potassium per 100 grams. Pineapples contain 146 mg of potassium per 100 grams. Tangerines contain 126 mg of potassium per 100 grams.
A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to: 1 Administer the prescribed antipyretic and notify the charge nurse or primary health care provider 2 Obtain the respirations, pulse, and blood pressure; recheck the temperature in one hour 3 Assess the amount and color of urine; obtain a specimen for a urinalysis 4 Note the consistency of respiratory secretions and obtain a specimen for culture
1 Administer the prescribed antipyretic and notify the charge nurse or primary health care provider Because an elevated temperature increases metabolic demands, the pyrexia must be treated immediately. The practitioner should be notified because this client is immunodeficient from both the disease and the chemotherapy. A search for the cause of the pyrexia can then be initiated. More vigorous intervention than obtaining the respirations, pulse, and blood pressure and rechecking the temperature in one hour is necessary. This client has a disease in which the immunoglobulins are ineffective and the therapy further suppresses the immune system. Assessing the amount and color of urine and obtaining a specimen for a urinalysis is not the immediate priority, although it is important because the cause of the pyrexia must be determined. Also the increased amount of calcium and urates in the urine can cause renal complications if dehydration occurs. Noting the consistency of respiratory secretions and obtaining a specimen for culture is not the priority, although important because respiratory tract infections are a common occurrence in clients with multiple myeloma.
The health care provider prescribes peak and trough levels of an antibiotic for a client who is receiving the medication intravenous piggyback (IVPB). For peak levels the nurse should have the laboratory obtain a blood sample from the client: 1 Between 30 and 60 minutes after the IVPB 2 Halfway between two IVPB administrations 3 Immediately before administering the IVPB 4 Anytime it is convenient for the client and laboratory
1 Between 30 and 60 minutes after the IVPB Because the drug was just administered, the blood level of the drug will be at its highest level. The result will reveal a drug blood level halfway between the peak and trough levels. The sample obtained immediately before administering the IVPB is done for a trough level when the drug level is at its lowest. Obtaining the sample anytime it is convenient for the client and laboratory will produce inaccurate results; peak and trough levels are measured in relation to the time a drug is administered.
A nurse is teaching a client about drug therapy for gonorrhea. Which fact about drug therapy should the nurse emphasize? 1 Cures the infection 2 Prevents complications 3 Controls its transmission 4 Reverses pathological changes
1 Cures the infection Ceftriaxone (Rocephin), followed by doxycycline (Vibramycin), is specific for Neisseria gonorrhoeae and eradicates the microorganism; other treatment regimens are available for resistant strains. If the disease progresses before the diagnosis is made, complications such as sterility, heart valve damage, or joint degeneration may occur. Transmission is not controlled; the organism is eliminated. If tubal structures, heart valves, or joints degenerate, the pathological changes will not be reversed by antibiotic therapy.
A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse? 1 Finding the client's contacts 2 Interviewing the client's parents 3 Instructing the client about birth control measures 4 Determining the reasons for the client's promiscuity
1 Finding the client's contacts Gonorrhea is a highly contagious disease transmitted through sexual intercourse. The incubation period varies, but symptoms usually occur 2 to 10 days after contact. Early effective treatment prevents complications such as sterility. The parents may be unaware that their child has gonorrhea. Most birth control measures do not protect against the transmission of sexually transmitted infections. Contracting venereal infection is not necessarily indicative of promiscuity.
An active adolescent is admitted to the hospital for surgery for an ileostomy. When planning a teaching session about self-care, the nurse includes sports that should be avoided by a client with an ileostomy. Which should be included on the list of sports to be avoided? (Select all that apply.) 1 Football 2 Swimming 3 Ice hockey 4 Track events 5 Cross-country skiing
1 Football 3 Ice Hockey Trauma to the abdominal wall and to the stoma should be avoided; contact sports, such as football and ice hockey, are contraindicated . Trauma to the abdominal wall is a minimal risk when swimming. Track events are not associated with trauma to the abdominal wall. Cross-country skiing is not associated with trauma to the abdominal wall.
When performing the initial history and physical examination of a client with a tentative diagnosis of peptic ulcer, the nurse expects the client to describe the pain as: 1 Gnawing epigastric pain or boring pain in the back 2 Located in the right shoulder and preceded by nausea 3 Sudden, sharp abdominal pain, increasing in intensity 4 Heartburn and substernal discomfort when lying down
1 Gnawing epigastric pain or boring pain in the back Classic symptoms of peptic ulcer include gnawing, boring, or dull pain located in the midepigastrium or back; pain is caused by irritability and erosion of the mucosal lining. Pain located in the right shoulder and preceded by a nausea-type of pain is more characteristic of cholecystitis. Sudden, sharp abdominal pain, increasing in intensity, is more characteristic of the complication of a perforated ulcer. Heartburn and substernal discomfort when lying down are more characteristic of a hiatal hernia.
A community health nurse is educating a client who is interested in discontinuing cigarette smoking. What should the teaching plan include? 1 Helping the client set a date to stop smoking 2 Referring the client to the American Red Cross 3 Encouraging the client to eat when the desire to smoke occurs 4 Telephoning the client several weeks after the preset target date
1 Helping the client set a date to stop smoking Setting a realistic target date to stop smoking can be motivating because it provides time to gather personal resources while committing to a specific time frame. The American Heart Association and the American Lung Association are appropriate agencies for referral, not the American Red Cross. Increasing eating may result in a weight gain that can precipitate reestablishing the habit of smoking to return to the former weight. The client should be called every three to five days, not weeks, after the target date for optimum support.
A nurse is concerned that a client with a diagnosis of cirrhosis of the liver may experience the complication of hepatic coma. For which clinical indicator should the nurse assess this client? 1 Icterus 2 Urticaria 3 Uremic frost 4 Hemangioma
1 Icterus Bile deposits will impart a yellowish tinge (jaundice or icterus) to the skin, often first observed in the sclerae. Urticaria (or hives) generally is characteristic of an allergic response. Uremic frost is characteristic of kidney failure. Hemangioma is a benign lesion composed of blood vessels.
A nurse is caring for a client who experienced a crushing chest injury. A chest tube was inserted. Which observation indicates a desired response to this treatment? 1 Increased breath sounds 2 Increased respiratory rate 3 Crepitus detected on palpation of the chest 4 Constant bubbling in the drainage collection chamber
1 Increased breath sounds The chest tube normalizes intrathoracic pressure, drains fluid and air from the pleural space, and improves pulmonary function. Increased respiratory rate may be a sign of pain, respiratory obstruction, or bleeding. Crepitus detected on palpation of the chest indicates that air has entered the subcutaneous tissue (subcutaneous emphysema). Constant bubbling in the drainage collection chamber indicates a probable leak in the drainage system.
A client with a long history of asthma is scheduled for surgery. What information should be included in preoperative teaching? 1 There is an increased risk of respiratory tract infections. 2 Relaxation techniques limit the severity of asthmatic attacks. 3 Coughing forcibly must be avoided because it increases the intrathoracic pressure. 4 Local anesthesia is preferred because it has fewer side effects than general anesthesia.
1 There is an increased risk of respiratory tract infections. Hypersecretion of the mucous glands provides an excellent warm, moist medium for microorganisms. Asthma is not a disease that is voluntarily controlled. Coughing must be encouraged; it prevents retention of mucus, which is an excellent medium for microorganisms. Excessive secretions also limit gaseous exchange. The anesthesiologist will make recommendations about the type of anesthesia best suited for the client and the surgical procedure.
Which response should the nurse expect when assessing a client who is dehydrated? (Select all that apply.) 1 Confusion 2 Bounding pulse 3 Sunken eyeballs 4 Dependent edema 5 Decreased blood pressure
1 Confusion 3 sunken eyeballs 5 decreased blood pressure Confusion occurs because of a decrease in cerebral perfusion. The eyes appear sunken because of decreased intracellular and extracellular fluid associated with dehydration. The blood pressure will be decreased with dehydration because of hypovolemia. The pulse will be rapid and thready with dehydration; a bounding pulse is associated with fluid volume excess. Dependent edema may occur with fluid volume excess, not deficit.
A client with gastroesophageal reflux disease (GERD) receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? (Select all that apply.) 1 Nizatidine (Axid) 2 Ranitidine (Zantac) 3 Famotidine (Pepcid) 4 Lansoprazole (Prevacid) 5 Metoclopramide (Reglan)
1 Nizatidine (Axid) 2 Ranitidine (Zantac) 3 Famotidine (Pepcid) Nizatidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Ranitidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Famotidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Lansoprazole is a proton pump inhibitor that inhibits gastric secretion up to 90% with one dose daily and provides for symptomatic improvement in GERD. Metoclopramide is a prokinetic agent that increases the rate of gastric emptying; it has multiple side effects and is not appropriate for long-term treatment of GERD.
A client with tuberculosis asks the nurse about the communicability of the disease. Which is the best response by the nurse? 1 "Tuberculosis is not communicable at this time." 2 "Untreated active tuberculosis is communicable." 3 "Tuberculosis is communicable during the primary stage." 4 "With the newer long-term therapies, tuberculosis is not communicable."
2 "Untreated active tuberculosis is communicable." The statement that untreated active tuberculosis is communicable is an accurate statement; treatment is necessary to stop communicability. The statement that tuberculosis is not communicable at this time is false reassurance; untreated active tuberculosis is communicable. Tuberculosis is not communicable when there is no active infection; the primary complex refers to the presence of a primary (Ghon) tubercle and enlarged lymph nodes and is the initial response to exposure; active disease may or may not occur. Tuberculosis is a communicable disease; close contacts should be screened via a skin test.
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. What is the primary purpose of the chest tube? 1 Lessens the client's chest discomfort 2 Restores negative pressure in the pleural space 3 Drains accumulated fluid from the pleural cavity 4 Prevents subcutaneous emphysema in the chest wall
2 Restores negative pressure in the pleural space Negative pressure is exerted by gravity drainage or by suction through the closed system. Though the discomfort may be lessened as a result of the insertion of the chest tube, this is not the primary purpose. There is an accumulation of air, not fluid, when a pneumothorax occurs in a client with COPD. Subcutaneous emphysema in the chest wall is associated most commonly with clients receiving air under pressure, such as that received from a ventilator.
Which test result should a nurse review to determine if the antibiotic prescribed for the client will be effective? 1 Serologic test 2 Sensitivity test 3 Serum osmolality 4 Sedimentation rate
2 Sensitivity test Infected body fluids are tested to determine the antibiotics to which the organism is particularly sensitive or resistant (sensitivity). The serologic test tests for antibody content. The serum osmolality test provides data about fluid and electrolyte balance. The erythrocyte sedimentation rate (ESR) is a nonspecific test for the presence of inflammation.
A client arrives at the clinic after being bitten by a raccoon in an area in the woods where rabies is endemic. When considering the client's needs, the nurse recalls that rabies is a: 1 Bacterial septicemia resulting in convulsions and a morbid fear of water 2 Viral infection characterized by convulsions and difficulty swallowing 3 Parasitic infestation characterized by encephalopathy and opisthotonos 4 Catalyst for an autoimmune response that results in a maculopapular rash and fever
2 Viral infection characterized by convulsions and difficulty swallowing Rabies is a viral infection characterized by convulsions and difficulty swallowing, which enters the body through a break in the skin and is characterized by convulsions and choking. Rabies is not associated with a bacterial septicemia; a virus causes it. Rabies is not caused by parasites; its outstanding characteristics are convulsions and choking. The virus does not attack the autoimmune system; it specifically attacks nervous tissue.
After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client says: 1 "Lately I can only breathe well if I sit up." 2 "During the night I sometimes get the chills." 3 "I get a sharp, stabbing pain when I take a deep breath." 4 "I'm coughing up larger amounts of thicker mucus for the last several days."
3 "I get a sharp, stabbing pain when I take a deep breath." Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.
A client has a Mantoux test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. The nurse concludes that this response indicates that the client has: 1 Contracted clinical tuberculosis 2 Passive immunity to tuberculosis 3 Been exposed to the tubercle bacillus 4 Developed a resistance to the tubercle bacillus
3 Been exposed to the tubercle bacillus Induration measuring 10 mm or more in diameter is interpreted as significant; it does not indicate that active tuberculosis is present. About 90% of individuals who have significant induration do not develop the disease. Exposure to the tubercle bacillus indicates exposure; infection can be past or present. Passive immunity occurs when the body plays no part in the preparation of the antibodies; a positive Mantoux indicates the presence of antibodies, not how they were formed. Developing a resistance to the tubercle bacillus reaction indicates exposure, not resistance.
A nurse is teaching a group of adults about the signs and symptoms of colorectal cancer. Which is the most common clinical manifestation that the nurse should include in the teaching program? 1 Nausea 2 Abdominal pain 3 Change in bowel habits 4 Alteration in caliber of stools
3 Change in bowel habits Constipation, diarrhea, or constipation alternating with diarrhea are the most common symptoms of colorectal cancer. Pain is reported as a symptom in less than 25% of clients; also, it is a late sign after other organs are invaded, intestinal obstruction occurs, or tissue necrosis develops. Alteration in caliber of stools is a later sign that becomes evident only when the lumen of the intestine narrows as a result of the enlarging mass. Nausea is typically not a symptom of colorectal cancer.
A client in the emergency department states, "I was bitten by a raccoon while I was fixing a water pipe in the crawl space of my basement." Which is the most effective first-aid treatment for the nurse to use for this client? 1 Administering an antivenin 2 Maintaining a pressure dressing 3 Cleansing the wound with soap and water 4 Applying a tourniquet proximal to the wound
3 Cleansing the wound with soap and water Infection is caused by viral contact with the dermal layer of skin; cleansing the wound with soap and water helps remove superficial contaminants. Antivenins are not effective against microbiological stresses. A pressure dressing will not prevent infection. Application of a tourniquet may impair circulation and will not prevent infection.
The nurse develops a plan of care related to a coughing and deep breathing regimen for a client who has had a pneumonectomy. The plan should include that, postoperatively, the client should cough and deep breathe: 1 Every 15 minutes for the first 24 hours and then every 2 hours 2 Every 30 minutes for the first 24 hours and then every 2 hours 3 Every hour for the first 24 hours and then every 2 hours 4 Every 2 hours for the first 24 hours and then every 3 hours
3 Every hour for the first 24 hours and then every 2 hours Excessive endotracheal secretions after a pneumonectomy require coughing routines that are effective but not exhausting. Every 15 minutes for the first 24 hours and then every 2 hours, and every 30 minutes for the first 24 hours and then every 2 hours are too exhausting. Every 2 hours for the first 24 hours and then every 3 hours is not specific for a client who has had a pneumonectomy.
A nurse is counseling a client who has gonorrhea. What additional fact about gonorrhea, besides the fact that it is highly infectious, should the nurse teach this client? 1 It is easily cured. 2 It occurs very rarely. 3 It can produce sterility. 4 It is limited to the external genitalia.
3 It can produce sterility. Inflammation associated with gonorrhea may lead to destruction of the epididymis in males and tubal mucosal destruction in females, causing sterility. Many gonococci have become penicillin resistant and difficult to treat. Gonorrhea is a common sexually transmitted infection. Neisseria gonorrhoeae will invade internal structures, particularly the epididymis in males and the fallopian tubes in females.
When caring for a client who is recovering from a gastrectomy, a nurse is concerned about the potential development of pernicious anemia. What should the nurse conclude may be the cause of this complication? 1 Vitamin B12 is just absorbed in the stomach. 2 Hemopoietic factor is secreted in the stomach. 3 Parietal cells of the stomach secrete the intrinsic factor. 4 Chief cells in the stomach promote the secretion of the extrinsic factor.
3 Parietal cells of the stomach secrete the intrinsic factor. Pernicious anemia is caused by a lack of vitamin B12 . Intrinsic factor, produced by the parietal cells of the gastric mucosa, is necessary for B12 absorption. B12 is absorbed in the ileum. The hemopoietic factor is the combination of B12 and intrinsic factor. The intrinsic factor is secreted by the stomach, and food is the source of vitamin B12 . Chief cells secrete the enzymes of the gastric juice.
When comparing ulcerative colitis and Crohn's disease, a nurse considers that they are similar yet dissimilar in many ways. What clinical manifestation is common to clients with Crohn's disease and not to clients with ulcerative colitis? 1 Diarrhea 2 Weight loss 3 Right lower quadrant pain 4 Decreased hematocrit
3 Right lower quadrant pain Right lower quadrant pain is typical with Crohn's disease; left lower quadrant pain is typical with ulcerative colitis. Diarrhea is common to both conditions to varying degrees. Weight loss is common to both conditions to varying degrees. Decreased hematocrit is common to both conditions to varying degrees.
What is the incubation period for an infectious disease? 1 The stage when acute symptoms of infection disappear 2 The length of time a patient manifests signs and symptoms 3 The interval between entrance of pathogen into body and appearance of first symptoms 4 The interval from onset of nonspecific signs and symptoms to more specific signs and symptoms
3 The interval between entrance of pathogen into body and appearance of first symptoms The incubation period is the interval between entrance of pathogen into body and appearance of first symptoms. The convalescence stage is the last stage characterized by disappearance of the symptoms related to the disease. The illness stage is the interval when patient manifests signs and symptoms specific to type of infection. The prodromal stage is the interval from onset of nonspecific signs and symptoms to more specific symptoms.
A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, the nurse anticipates a prescription for: 1 High fat diet 2 Supplemental cod liver oil 3 Total parenteral nutrition (TPN) 4 Water-soluble forms of vitamins A and E
4 Water-soluble forms of vitamins A and E Vitamins A, D, E, and K are known as fat-soluble vitamins because bile salts and other fat-related compounds aid their absorption. A high fat diet will not achieve the uptake of fat-soluble vitamins in this client. Supplemental cod liver oil will not achieve the uptake of fat-soluble vitamins in this client. TPN is unnecessary; a well-balanced diet is preferred. Water-miscible forms of vitamins A and E can be absorbed with water-soluble nutrients.
A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? (Select all that apply.) 1 Lettuce 2 Oranges 3 Broccoli 4 Apricots 5 Strawberries
Correct 2 Oranges Correct 3 Broccoli Correct 5 Strawberries One cup of fresh orange sections contains 96 mg of vitamin C. Vitamin C (ascorbic acid), an antioxidant, is found in vegetables such as broccoli, tomatoes, and potatoes; 1 cup of broccoli contains 140 mg of vitamin C. A cup of strawberries contains 106 mg of vitamin C. Apricots contain 11 mg of vitamin C; they are a source of beta-carotene. An entire head of lettuce contains 13 mg of vitamin C.
A health care provider prescribes an upper gastrointestinal (GI) series and a barium enema. The client asks, "Why do I have to have barium for these tests?" The nurse's best response is "Barium: 1 Gives off visible light, illuminating the alimentary tract." 2 Provides fluorescence, thereby lighting up the alimentary tract." 3 Dyes the structures of the alimentary tract, making them more visible." 4 Gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."
Correct 4 Barium salts used in a GI series and barium enemas coat the inner lining of the GI tract and then absorb x-rays passing through. Thus, they outline the surface features of the tract on a photographic plate. Barium has no light-emitting properties. Barium does not fluoresce. Barium does not have the properties of a dye.
hiamine (vitamin B1) and niacin (vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? 1 Neuronal activity 2 Bowel elimination 3 Efficient circulation 4 Prothrombin development
Correct1 Neuronal activity Thiamine and niacin help convert glucose for energy, and therefore influence nerve activity. These vitamins do not affect elimination. These vitamins are not related to circulatory activity. Vitamin K, not thiamine and niacin, is essential for the manufacture of prothrombin.
A client is scheduled for ligation of hemorrhoids. Which diet does the nurse expect to be prescribed in preparation for this surgery? 1 Bland 2 Clear liquid 3 High-protein 4 Low-residue
Correct4 Low-residue A low-residue diet limits stool formation. Bland diets usually are employed in the management of upper, not lower, gastrointestinal disturbances. Although a clear diet is low in residue, it does not meet nutritional needs. A high-protein diet is indicated postoperatively to promote healing.
A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for signs that strangulation of the intestine may have occurred. What is an early sign of strangulation? 1 Increased flatus 2 Projectile vomiting 3 Sharp abdominal pain 4 Decreased bowel sounds
3 Sharp abdominal pain Pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia. Flatus is impeded by strangulation. Vomiting is persistent, not projectile. Decreased bowel sounds are not an early sign of obstruction; decreased bowel sounds occur after gas and fluid accumulate.
A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience: 1 Transient headaches." 2 An elevated temperature." 3 Paroxysmal hiccoughs." 4 A sore throat."
4 A sore throat." A general anesthetic is delivered via an endotracheal tube that irritates the posterior pharynx and larynx. Side effects of general anesthesia do not include transient headaches or an elevated temperature. Hiccoughs, headaches, and an elevated temperature are systemic effects, not local effects, and are not side effects of general anesthesia
A client asks the nurse to review a list of the foods the client has been choosing to combat constipation. Upon review, the nurse identifies that the food item that has the least amount of fiber content is: 1 Stewed prunes 2 Whole-bran cereal 3 Grapefruit sections 4 Cream of wheat cereal
4 Cream of wheat cereal Cream of wheat cereal is highly refined, with reduced fiber content. Prunes are high in bulk and promote intestinal motility. The fiber residue of whole-bran cereal promotes intestinal motility. The fiber residue of grapefruit sections promotes intestinal motility.
A client with chronic bronchitis smokes one or two cigarettes a day and has not been performing the prescribed pulmonary physiotherapy exercises because they are too tiring. What is the best response by the nurse? 1 "Tell me about your typical day before the exercises were prescribed." 2 "Smoking is probably the cause of the severity of your disease at this time." 3 "Your being so sick is probably because of your smoking, and your choosing not to exercise." 4 "I can't make you stop doing what you are doing, and it's your choice to be sick or well."
1 "Tell me about your typical day before the exercises were prescribed." More data are needed about activities of daily living to evaluate noncompliance before revising the care plan. "Smoking is probably the cause of the severity of your disease at this time," "Your being so sick is probably because of your smoking, and your choosing not to exercise," and "I can't make you stop doing what you are doing, and it's your choice to be sick or well" are nonproductive responses because it places blame for the illness on the client.
What nursing action will limit hypoxia when suctioning a client's airway? 1 Apply suction only after catheter is inserted. 2 Limit suctioning with catheter to half a minute. 3 Lubricate the catheter with saline before insertion. 4 Use a sterile suction catheter for each suctioning episode.
1 Apply suction only after catheter is inserted. The negative pressure from suctioning removes oxygen as well as secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Limiting suctioning with catheter to half a minute is too long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.
Before the nurse can be an advocate for a client who is homosexual who has acquired immunodeficiency syndrome (AIDS), the nurse needs to do what? 1 Reveal to clients the nurse's personal sexual identity 2 Identify personal attitudes and feelings about homosexuality 3 Have a commitment to treat all patients equally 4 Admit feelings of being uncomfortable around the client
2 Identify personal attitudes and feelings about homosexuality Before nurses can be client advocates, they must understand themselves, particularly regarding issues that may affect clients; this is the first step toward providing nonjudgmental care. It is not necessary for the nurse to discuss the nurse's sexual identity to clients. Although it is beneficial for nurses to examine themselves, this does not mean that the care will be nonjudgmental. Although having a commitment to treat all patients equally is important, the nurse should first thoroughly self assess attitudes, values, and beliefs. Although truthfulness is important in a therapeutic relationship, the nurse should attempt to be nonjudgmental.
A nurse caring for a client who has gastroesophageal reflux disease (GERD) should place the client in what position in the illustration?
The reverse Trendelenburg position uses gravity to help keep gastric contents in the stomach, thereby minimizing reflux of gastric contents into the esophagus. The high-Fowler position promotes lung expansion; it is used when the client eats in bed and when the nurse suctions secretions from the client's respiratory tract. The client can slide down lower in bed while in the semi-Fowler position, which puts undue stress on the stomach, contributing to reflux. The flat position may permit the flow of gastric contents through the cardiac sphincter into the esophagus, contributing to GERD and increasing the risk of aspiration.