med surg chapter 52
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first?
Heart rate and rhythm
The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect?
High-pitched, rushing bowel sounds in the right lower quadrant
A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions?
Serum potassium of 2.6 mEq/L (2.6 mmol/L)
The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect?
Severe, steady right lower quadrant pain
The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action?
Skin protection
The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug?
"Do you have any allergy to sulfa drugs?"
The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching?
"Drink plenty of fluids to prevent dehydration."
After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?
"I will take a laxative nightly at bedtime to avoid becoming constipated."
After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?
"I will take this medication with my breakfast each morning."
The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching?
"I'll cook all the meals for my family."
A nurse cares for a young client with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How would the nurse respond?
"Let's talk to the ostomy nurse about options for ostomy supplies and dress styles."
A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How would the nurse respond?
"Tell me more about your concerns."
The nurse teaches a community group ways to prevent Escherichia coli infection. Which statements would the nurse include in this group's teaching? (Select all that apply.)
"Wash your hands after any contact with animals." "Use separate cutting boards for meat and vegetables."
A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include?
"You should be able to have better bowel continence after healing occurs."
A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.)
Administer pain medications as prescribed. Palpate the abdomen for distention. Assess for sudden changes in mental status. Evaluate stools for occult blood.
A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.)
Anorexia Constipation Abdominal pain
After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching?
Baked fish with steamed carrots and a glass of apple juice
The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder?
Consuming raw seafood
After teaching a patient who has a permanent ileostomy, a nurse assesses the client's understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.)
Corn String beans Wheat rice
A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.)
Does your gym provide yoga classes? When should you contact your provider? What do you plan to eat for dinner? How many bathrooms are in your home?
The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect?
Elevated leukocyte count
The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)
Lower gastrointestinal bleeding—erosion of the bowel wall Abscess formation—localized pockets of infection develop in the ulcerated bowel lining Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer
The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.)
Nausea and vomiting Abdominal pain Bradycardia Decreased urinary output Fever
The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.)
Need to have drug administered by a primary health care provider. Need to avoid crowds and individuals who have infection. Awareness of a rare but potentially fatal drug complication. Need to report any signs and symptoms of infection immediately.
The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider?
Pale and bluish stoma
A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.)
Use medicated wipes instead of toilet paper. Apply a thin coat of aloe cream to the perineum. Gently pat the perineum dry after cleansing.
