NURS 131 Chapter 34

a

A client with ulcerative colitis has severe diarrhea. Further assessments by the nurse are aimed at early recognition of a) dehydration. b) hemorrhoids. c) metabolic alkalosis. d) nephrolithiasis.

c

A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patients symptoms? a) What type of foods do you eat? b) Is it possible that you are pregnant? c) Can you tell me more about the pain? d) What is your usual elimination pattern?

a,

A 57-year-old client with peptic ulcer disease is being seen for abdominal pain. Which of the following are assessments for hemorrhage in this client? Select all that apply. a) Assessing for symptoms of dizziness or nausea b) Speaking calmly to the client to reduce anxiety c) Administering stool softeners d) Recording hourly urinary output e) Monitoring the client's hemoglobin and hematocrit levels

b

A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a) Encourage the patient to increase oral fluid intake. b) Assess the patient about risk factors for constipation. c) Suggest that the patient increase intake of high-fiber foods. d) Teach the patient that a daily bowel movement is unnecessary.

a

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?a. Have you been experiencing any constipation?b. Are you eating a diet high in fiber and fluids?c. Do you have a history of high blood pressure?d. What vitamins and supplements are you taking?

a

A nurse is caring for a postoperative client who has developed peritonitis. An assessment finding that would require immediate action would be a) a decrease in blood pressure of more than 15 mm Hg. b) an increase in urine output of more than 300 ml/day. c) pulse deficit of more than 20 beats/minute. d) weight gain of more than 5 pounds.

a) fresh fruits because they are high in fiber and can cause diarrhea

The nurse is reinforcing patient teaching. Which of the following foods would the nurse reinforce that the patient with ulcerative colitis is to avoid? a) fresh fruits b) white bread c) sweet dessert d) meat

c

The nurse is caring for a client with irritable bowel syndrome (IBS) with constipation. Which medication can the nurse expect to administer? a) Nortriptyline b) Dicyclomine c) Fluoxetine d) Rifaximin

a

The nurse is caring for a group of clients. Which client is at highest risk for developing ulcerative colitis? a) A 20-year-old with thyroid cancer who received radiation b) A 35-year-old who smokes cigarettes occasionally c) A 40-year-old who works in a bank and drinks socially d) A 55-year-old who is a health conscious and regularly eats vegetables

a) obtain vital signs because this could be signs of an upper GI bleed

The nurse is caring for a patient who has a sudden onset of diarrhea with black tarry stools. Which action should the nurse take? a) obtain a set of vital signs b) monitor output c) ask about history of food allergies d) place the patient on NPO

a,b,c,d,f) All but edema are a priority in order to detect pain, dehydration, infection, or shock.

The nurse is caring for a patient with a small-bowel obstruction who is NPO with an orogastric tube on low intermittent suction. Which of the following ongoing data would be a priority for the nurse to monitor and collect? (Select all that apply) a) Intake and Output b) Pain Level c) Temperature d) Pulse rate e) Edema f) Firmness of abdomen or distention

c

The nurse is performing a stool test for occult blood. Which substance can contribute to a false-positive result? a) Antibiotics b) Ingestion of carrots c) Anticoagulants d) Ingestion of apples

a

The nurse caring for a client with abdominal distention and vomiting that is fecal in nature should conduct further assessment aimed at discovering a) a distal, small intestinal obstruction. b) gastric ulceration. c) gastrointestinal (GI) bleeding. d) ulceration of the esophagus.

c

The nurse caring for a client with an intestinal malignancy assesses for bleeding, which would most likely be manifested by a) abdominal discomfort. b) hematemesis. c) hematochezia. d) hypotension.

d

The nurse has received report on 4 clients. All clients have pantoprazole ordered. Which client will need this medication first? a) A client with a gallstone b) A client with a DVT c) A client with hypovolemia d) A client with a GI bleed

a,d,e

The nurse is caring for a client with an intestinal ulcer who takes lansoprazole. The nurse knows to monitor the client for which of the following adverse reactions? Select all that apply. a) headache b) oliguria c) anxiety d) nausea e) diarrhea

c

The nurse is teaching a client about a barium enema. Which statement by the client indicates an understanding of the teaching? a) "I will eat a high-residue diet for several days before the test." b) "I will have nothing by mouth for 2 hr before the test." c) "I need to take a laxative and enema the night before the test." d) "I can have only clear liquids for 8 hr before the test."

d) Because coughing is contraindicated to prevent damaging the repair, but deep breathing should be done every hour while the patient is awake.

The nurse participated in a patient's teaching session for care to prevent respiratory complications after a hernia repair. Which statement by the patient would indicate to the nurse that the patient understood the teaching? a) "I will cough every hour while awake." b) "I will deep breathe four times a day." c) "I will cough and deep breathe every hour." d) "I will deep breathe every hour while awake."

a

The nurse taking the history of an 80-year-old woman diagnosed with gastroenteritis would recognize that the most significant factor in determining potential for complications in this client is a) age. b) family history. c) gender. d) prior bouts of gastroenteritis.

a

Until a diagnosis is made, the nurse caring for a client being evaluated for acute appendicitis should treat pain and discomfort with a) comfort touch and reassurance. b) frequently changing the clients position. c) narcotic pain medication. d) warm compresses applied to the belly.