Honan Practice Questions
Which assessment finding does the nurse expect as a normal consequence of aging? A. Increased salivation and drooling B. Hyperactive bowel sounds and loose stools C. Increased gastric production and heartburn D. Decreased sensation to defecate and constipation
D. Decreased sensation to defecate and constipation Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production.
Which of the following is the most effective strategy to prevent hepatitis B infection? Vaccine Barrier protection during intercourse Covering open sores Avoid sharing toothbrushes
Vaccine The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.
A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? Weight loss Diarrhea Fatigue Hypertension
Weight loss Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: yellow sclerae. light amber urine. circumoral pallor. black, tarry stools.
yellow sclerae. Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis? Liver biopsy CT scan Prothrombin time Platelet count
A liver biopsy A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding
The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? A. Hematemesis B. Bradycardia C. Hypertension D. Polyuria
A. Hematemesis The nurse interprets hematemesis as a sign/symptom of possible hemorrhage from the ulcer. Other signs that can indicate hemorrhage include tachycardia, hypotension, and oliguria/anuria.
A patient complains of abdominal pain and distention, fever, tachycardia, and diaphoresis. An abdominal x-ray shows free air under the diaphragm. The emergency department nurse should suspect which condition? A. Intestinal obstruction B. Malabsorption C. Intestinal perforation D. Acute cholelithiasis
C. Intestinal perforation Free air in the abdomen may result from a perforation of the abdominal organ or any part of the bowel, a tumor, or trauma.
A client has undergone a liver biopsy. Which postprocedure position is appropriate? On the left side Trendelenburg On the right side High Fowler's
On the right side In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on his left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.
Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Appendicitis Pancreatitis Cholecystitis Peptic ulcer
Pancreatitis Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.
A 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses? Hepatitis A Hepatitis B Hepatitis C Hepatitis D
Hepatitis C Transmission of hepatitis C occurs primarily through injection of drugs and through transfusion of blood products prior to 1992. Hepatitis A, B, and D are less likely to result from IV drug use.
A client with calculi in the gallbladder is said to have Cholecystitis Cholelithiasis Choledocholithiasis Choledochotomy
Cholelithiasis Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.
When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? Yellow-green Black and tarry Blood tinged Clay-colored or whitish
Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.
Which is a clinical manifestation of cholelithiasis? Epigastric distress before a meal Clay-colored stools Abdominal pain in the LUQ Nonpalpable abdominal mass
Clay-colored stools The client with gallstones has clay-colored stools and excruciating RUQ pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.
The nurse recognizes that most nutrients and electrolytes are absorbed by which organ? A. Esophagus B. Stomach C. Colon D. Small intestine
D. Small intestine The small intestine absorbs most of the nutrients and electrolytes. The colon absorbs water, sodium, and chloride from the digested food that has passed from the small intestine. The esophagus moves food from the mouth to the stomach, which stores food during eating and secretes digestive fluids.
A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? Serum calcium Serum bilirubin Serum amylase Serum potassium
Serum amylase Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.
A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has a history of alcohol abuse. What would the nurse suspect the patient has? Hemolytic jaundice Hepatic insufficiency Bleeding esophageal varices Portal hypertension
Bleeding esophageal varices The patient with bleeding esophageal varices may present with hematemesis, melena, or general deterioration in mental or physical status and often has a history of alcohol abuse. Signs and symptoms of shock (cool clammy skin, hypotension, tachycardia) may be present. The scenario does not describe hemolytic jaundice, hepatic insufficiency, or portal hypertension.
A confused patient prematurely removes her NG tube. The nurse knows to observe for which complication? A. Constipation B. Flatulence C. Abdominal distention D. Gastric bleeding
C. Abdominal distention If the tube is not replaced after its removal, the nurse should watch for abdominal distention, nausea, and vomiting. Constipation is not a complication associated with NG tube removal. Flatulence indicates air is passing through the GI tract. Gastric bleeding is not associated with removal of an NG tube, as the tubes are often soft and flexible.
A patient returns to his room following a diagnostic colonoscopy after radiologic evidence of diverticulosis. He reports an increase in abdominal pain, fever, and chills. Which clinical condition is most concerning to the nurse? A. Colon cancer B. Hemorrhoids C. Bowel perforation D. Anal fissure
C. Bowel perforation During a colonoscopy, manipulation of the bowel occurs, which can cause peritonitis or bowel perforation. Signs and symptoms of a perforated bowel include abdominal pain, fever, and chills. The patient may have guarding (not allowing palpation of the abdomen), rigidity, and firmness of the abdomen, or rebound tenderness (an increase of pain upon releasing pressure on the abdomen).
What assessment finding supports a client's diagnosis of gastric ulcer? A. Presence of blood in the client's stool for the past month B. Complaints of sharp pain in the abdomen after eating a heavy meal C. Periods of pain shortly after eating any food. D. Complaints of epigastric burning that moves like a wave
C. Periods of pain shortly after eating any food. Experiencing sharp pain 30 to 60 minutes after meals is common with gastric ulcers; patients with duodenal ulcers can have night pain that is relieved by eating.
A patient presents to the walk-in clinic complaining of vomiting and burning in his mid-epigastria. The nurse knows that to confirm peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. Gastric irritation caused by nonsteroidal anti-inflammatory drugs (NSAIDs) D. Inadequate production of pancreatic enzymes
A. Infection with Helicobacter pylori H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Other less invasive diagnostic measures for detecting H. pylori include serologic testing for antibodies against the H. pylori antigen, stool antigen test, and urea breath test. Excessive stomach acid secretion, NSAIDs, and dietary indiscretion may all cause gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Reference:
An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: Acetaminophen Ibuprofen Dextromethorphan Benadryl
Acetaminophen Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents. MAX YOU CAN TAKE PER DAY IS 4,000 MG
A nurse working on a general medical-surgical floor is discussing the clinical manifestations of pulmonary arterial hypertension (PAH) with a recent nursing graduate. What is the main symptom of PAH that the nurse would explain? A. Chest pain B. Fatigue C. Dyspnea D. Hemoptysis
C. Dyspnea Dyspnea, the main symptom of both types of PAH, first occurs with exertion and eventually at rest. Other signs and symptoms include chest pain, weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure.
A patient is receiving thrombolytic therapy for treatment of a pulmonary emboli. For what side effect should the nurse must monitor the patient? A. Chest pain B. Rash C. Hyperthermia D. Bleeding
D. Bleeding Thrombolytic therapy dissolves the thrombi or emboli more quickly and restores more normal hemodynamic functioning of the pulmonary circulation, thereby reducing pulmonary hypertension and improving perfusion, oxygenation, and cardiac output. However, bleeding is a significant side effect. Chest pain, a rash, and elevated temperature are not therapy-specific side effects associated with the use of thrombolytics.
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Getting the flu can complicate pneumonia." "Influenza vaccine will prevent typical pneumonias." "Influenza is the major cause of death in the United States." "Viruses like influenza are the most common cause of pneumonia."
"Viruses like influenza are the most common cause of pneumonia." Influenza type A is the most common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.
Which question will best assist the nurse in the assessment of a patient with acute diarrhea? A. "Have you had a colonoscopy in the last 3 months?" B. "Have you traveled outside the country recently?" C. "Do you have any trouble swallowing?" D. "Do you have any allergies?"
B. "Have you traveled outside the country recently?" A history of recent travel may help pinpoint an infectious source for the patient's diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.
A patient is complaining of right lower quadrant pain, fever, and decreased appetite. What does the nurse suspect is the most likely cause? A. Diverticulitis B. Appendicitis C. Small bowel obstruction D. Sigmoid colon cancer
B. Appendicitis The signs and symptoms of appendicitis include right lower quadrant pain, increased fever and WBC counts, and a decreased appetite. The patient may also complain of nausea and vomiting, and the pain may radiate into the umbilical area.
A patient complains of abdominal pain unrelieved by defecation, that typically occurs after meals along with diarrhea. What does the nurse recognize as the most likely diagnosis? A. Ulcerative colitis B. Regional enteritis C. Cholecystitis D. Diverticulosis
B. Regional enteritis Regional enteritis, or Crohn's disease, typically presents with cramp/spasm-type abdominal pain that worsens after meals. It often also presents with diarrhea.
A 47-year-old man with epigastric pain is being admitted to the hospital. During the admission assessment and interview, what specific information should the nurse obtain from the patient, who is suspected of having peptic ulcer disease? Any allergies to food or medications Use of NSAIDs Medical history for two previous generations History of side effects of all medications
B. Use of NSAIDs Use of NSAIDs in the patient suspected of peptic ulcer disease increases the risk of GI bleeding.
A nurse receives report on a patient experiencing dumping syndrome. The nurse knows that the patient would be displaying which symptom 30 minutes after eating? A. Difficulty swallowing B. Heartburn C. Nausea D. Cramping in the abdomen
C. Nausea D. Cramping in the abdomen Patients with dumping syndrome are diaphoretic, dizzy, and weak. They also complain of nausea, vomiting, belching and epigastric fullness as well as diarrhea and abdominal cramping. The symptoms are caused by fluid shift in the intestine due to the high tonicity of the feedings. Difficulty swallowing is a common symptom of esophageal diverticulum. Heartburn is associated with GERD.
A patient has a bowel perforation from a recent surgery and now has been diagnosed with peritonitis. The patient has hypoactive bowel sounds, a temperature of 100.5°F, and an elevated WBC count. What is the most serious potential complication of peritonitis for which the nurse should monitor? A. Nausea B. Diarrhea C. Sepsis D. Abdominal tenderness
C. Sepsis Sepsis is the major cause of death from peritonitis. Shock may result from septicemia or hypovolemia. The inflammatory process may cause intestinal obstruction, primarily from the development of bowel adhesions, and care must be made to closely monitor the patient's nasogastric tube drainage and input and output. Diarrhea would normally not occur due to intestinal obstruction, which causes decreased peristalsis and decreased bowel movements. Nausea and abdominal tenderness are expected as clinical manifestations of peritonitis.
The client with a peptic ulcer is admitted to the hospital's intensive care unit with obvious gastric bleeding. What is the priority intervention for the nurse? A. Keep an accurate record of intake and output. B. Provide for quiet environment, restrict visitors. C. Prepare the client for an endoscopy. D. Monitor vital signs and observe for signs of hypovolemia.
D. Monitor vital signs and observe for signs of hypovolemia. The goal is to directly stop the bleeding and remove blood/clots/secretions from GI tract so that an endoscopy can be performed and the patient does not vomit and aspirate gastric contents.
When performing an abdominal assessment on a patient with suspected cholecystitis, how does the nurse palpate the patient's abdomen? A. Palpate the right lower quadrant only B. Palpate the upper quadrants only C. Defer palpation and use percussion only D. Palpate the right upper quadrant last
D. Palpate the right upper quadrant last The patient with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the patient from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. Palpation is an important assessment tool that should not be deferred for this patient.
The nurse is administering liquids to a patient who has recently been changed from NPO to a clear liquid diet. The patient coughs and occasionally gags with sips of water. Which health care team member would the nurse consult? A. Physical therapist B. Respiratory therapist C. Dietician D. Speech pathologist
D. Speech pathologist After the nurse stops giving the patient oral liquids, they would consult the speech pathologist for a swallowing evaluation. Physical therapists assist patients in regaining motor strength and mobility. Respiratory therapists assess and manage respiratory function and associated treatments. Dieticians evaluate the caloric needs of the patients with various illnesses and determine the correct diet to promote recovery.
What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct? Colonoscopy Abdominal x-ray Cholecystectomy Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.
A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include? Hepatitis B is transmitted primarily by the oral-fecal route. Hepatitis A is frequently spread by sexual contact. Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis G is similar to hepatitis A.
Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the client for pulmonary surgery
Intubate the client and control breathing with mechanical ventilation A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? Coagulation studies Magnetic resonance imaging Radioisotope liver scan Liver biopsy
Liver biopsy A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it. These tests provide information about the liver's enlarged size, nodular configuration, and distorted blood flow.
Which is the most common cause of esophageal varices? Jaundice Portal hypertension Ascites Asterixis
Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.
A patient has been brought to the emergency department (ED) by the paramedics. The patient is suspected of having acute respiratory distress syndrome (ARDS). What action should the nurse anticipate? Preparing to assist with intubating the patient Setting up oxygen at 3 LPM by nasal prongs Consulting physiotherapy Setting up a nebulizer
Preparing to assist with intubating the patient A patient who has ARDS usually requires mechanical ventilation with a higher than normal airway pressure. While oxygen, nebulizer, and physiotherapy will be used at various stages of the treatment of ARDS, the priority is to secure the airway.
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? Rapid onset of severe dyspnea Inspiratory crackles Bilateral wheezing Cyanosis
Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.
The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital? Severe abdominal pain Fever Jaundice Mental agitation
Severe abdominal pain Severe abdominal pain is the major symptom of pancreatitis that causes the patient to seek medical care. Abdominal pain and tenderness and back pain result from irritation and edema of the inflamed pancreas.
A mediastinal shift occurs in which type of chest disorder? Tension pneumothorax Traumatic pneumothorax Simple pneumothorax Cardiac tamponade
Tension pneumothorax A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: cirrhosis. peptic ulcer disease. appendicitis. cholelithiasis.
cirrhosis. Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.
Which symptoms will a nurse observe most commonly in clients with pancreatitis? Severe, radiating abdominal pain Black, tarry stools and dark urine Increased and painful urination Increased appetite and weight gain
severe, radiating abdominal pain The most common symptom in clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back.