Ch 52 & 53

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? a. Serum potassium of 2.6 mEq/L (2.6 mmol/L) b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 (8.2 x 10^9/L) d. Client's weight decreased by 3 lb (1.4 kg)

ANS: A Fistulas place the patient with Crohn disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and would cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

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.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

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? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with my breakfast each morning." c. "Nausea and vomiting are common side effects of this drug." d. "I should wash my hands after I play with my dog."

ANS: B Adalimumab is an immune modulator that is given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

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? a. "Your friends will be happy that you are alive." b. "Tell me more about your concerns." c. "A therapist can help you resolve your concerns." d. "With time you will accept your new body."

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse would encourage the client to discuss concerns by restating them in an open-ended manner. The nurse would not minimize the client's concerns or provide false reassurance.

The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis

ANS: B, C, D The client who has hepatitis C has complications that do not relate to the liver, including polyarthritis, myalgia, heart disease and vasculitis, renal disease, and cognitive impairment.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client would have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this patient than heart rate and rhythm.

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? a. "I'll ride my bike or take a long walk at least three times a week." b. "I must try to include at least 25 g of fiber in my diet every day." c. "I will take a laxative nightly at bedtime to avoid becoming constipated." d. "I should use my legs rather than my back muscles when I lift heavy objects."

ANS: C Laxatives are not recommended for patients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? a. "I won't let anyone use my dishes or glasses." b. "I'll wash my hands with antibacterial soap." c. "I'll keep my bathroom extra clean." d. "I'll cook all the meals for my family."

ANS: D All of these statements are correct except for that the client should not prepare meals for others to help prevent transmission of gastroenteritis.

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C

ANS: D Hepatitis C is the leading cause of cirrhosis and an also cause liver cancer. Clients with nonalcoholic fatty liver disease often have metabolic syndrome and can also develop cirrhosis.

The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding

ANS: A Elbasvir can cause liver toxicity and therefore the nurse would assess for a history of or current hepatitis B.

The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? a. Decreased potassium level b. Increased sodium level c. Elevated leukocyte count d. Decreased thrombocyte count

ANS: C Appendicitis is an acute inflammatory disorder that frequently results in elevation of leukocytes (white blood cells). Serum electrolytes are not affected because the client does not usually have diarrhea. Thrombocyte (platelet) count is unrelated to this GI disorder.

The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

ANS: A Although family members may be afraid that they will contract hepatitis C, the nurse would educate them about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needlesticks, unsanitary tattoo equipment, and sharing of intranasal drug paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.

The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg)

ANS: A Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. To prevent hypovolemic shock, no more than 2000 mL are usually removed from the abdomen at one time. The patient's weight typically only decreases by less than 2 kg or 4.4 lb.

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? a. "You will have to wear an appliance for your permanent ileostomy." b. "You should be able to have better bowel continence after healing occurs." c. "You will have a large abdominal incision that will require irrigation." d. "This procedure can be performed under general or regional anesthesia."

ANS: B A RCA-IPAA can improve bowel continence although leakage may still occur for some clients. The procedure is a 2-step process performed under general anesthesia using a laparoscope which does not require an abdominal incision or permanent ileostomy.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."

ANS: B Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

ANS: B The route of transmission for hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.) a. Weight gain b. Anorexia c. Constipation d. Anal fistula e. Abdominal pain

ANS: B, C, E Signs and symptoms of celiac disease include weight loss, anorexia, constipation, and abdominal pain. Anal fistulas are not associated with celiac disease.

A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."

ANS: C Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client.

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French

ANS: C The Patatin-like phospholipase domain containing 3 gene (PNPLA3) has been identified as a risk gene for cirrhosis, which occurs most often in Latinos when compared to other populations.

The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment

ANS: D A postprocedure complication of a TIPS procedure is right-sided heart failure. Therefore, the nurse would perform a cardiovascular assessment before the procedure to determine if the client has signs and symptoms of heart failure.

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug."

ANS: D Lamivudine can cause renal impairment and the nurse would remind the client of changes that may indicate kidney damage.

The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.

The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 L of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

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? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-tinged output

ANS: A The nurse would assess the stoma for color and contact the primary health care provider if the stoma is pale, bluish, or dark because these changes indicate possible lack of perfusion. The nurse would expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."

ANS: A The purpose of administering lactulose to this patient is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The patient must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse would not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine

ANS: A, B, C, D, E, F All of these assessment findings are very common for a client who has late-stage cirrhosis due to biliary obstruction and poor liver function. The client has vascular lesions and excess fluid from portal hypertension.

The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"

ANS: A, B, C, D, E, F The nurse would ask all of these questions because "baby boomers," people who use illicit drugs, people on hemodialysis, health workers, and prisoners are at a very high risk for hepatitis C. Additionally, individuals who received blood, blood products, or an organ transplant prior to 1992 before bloodborne disease screening of these products was mandated are at risk for hepatitis C.

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.) a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? d. Do you have a scale for daily weights? e. How many bathrooms are in your home?

ANS: A, B, C, E A home assessment for a client who has a chronic inflammatory bowel disease would include identifying adequacy and availability of bathroom facilities, opportunities for rest and relaxation, and the client's knowledge of dietary therapy, and when to contact the primary health care provider. The client does not need to perform daily weights.

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.) a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. d. Provide the client with a high-fiber diet. e. Evaluate stools for occult blood.

ANS: A, B, C, E When caring for an older adult who has diverticulitis, the nurse would administer analgesics as prescribed, palpate the abdomen for distention and tenderness, assess for confusion and sudden changes in mental status, and check stools for occult or frank bleeding. A low-fiber/residue diet would be provided when symptoms are present and a high-fiber diet when inflammation resolves.

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.) a. Corn b. String beans c. Carrots d. Wheat rice e. Squash

ANS: A, B, D Clients with an ileostomy should be cautious of high-fiber and high-cellulose foods including corn, string beans, and rice. Carrots and squash are low-fiber items.

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer e. Fistula—dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

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.) a. Need to have drug administered by a primary health care provider. b. Need to avoid crowds and individuals who have infection. c. Need to report injection reactions such as redness and swelling. d. Awareness of a rare but potentially fatal drug complication. e. Need to report any signs and symptoms of infection immediately.

ANS: A, B, D, E All of these choices are correct except that the drug is given intravenously. Therefore, there is no need to teach the client to report injection reactions because the client does not self-administer the medication subcutaneously. Natalizumab can cause progressive multifocal leukoencephalopathy (PML), but it is a very rare disorder causing cognitive, sensory, and/or motor changes.

The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection b. GI bleeding c. Irritable bowel syndrome d. Constipation e. Anemia f. Hypovolemia

ANS: A, B, D, F Anemia and irritable bowel syndrome are unrelated to developing or worsening encephalopathy, which is caused by increased protein which breaks down into ammonia. Infection can cause hypovolemia which would increase serum protein concentration. Constipation and GI bleeding causes a large protein load in the intestines.

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the patient." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush would be used to prevent gum bleeding, and the client's nails would need to be trimmed short to prevent the patient from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever

ANS: A, C, D, E, F Peritonitis is an acute inflammatory disorder. Therefore, the client would likely have all of these signs and symptoms but would have tachycardia rather than bradycardia due to dehydration from fever.

The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy f. Respiratory therapy

ANS: A, C, D, F Care for a client who has hepatopulmonary syndrome would include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the patient in a prone position, on the patient's stomach. Although physical therapy may be helpful to a patient who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome. However, respiratory support from a specialized therapist may be needed.

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.) a. Cleanse the perineum with an antibacterial soap. b. Use medicated wipes instead of toilet paper. c. Identify foods that decrease constipation. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

ANS: B, D, E To prevent skin excoriation from frequent bowel movements associated with inflammatory bowel disease, the nurse would encourage good skin care with a mild soap and water and gently patting the area dry after each bowel movement. Using medicated wipes instead of toilet paper and applying a thin coat of aloe cream are appropriate. The client should identify and avoid foods that increase diarrhea. Antibacterial soaps are harsh and should not be used.

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

ANS: B A low-protein diet is prescribed when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the patient's dietary protein will cause complications of liver failure and would not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.

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? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B Protecting the client's skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn disease also includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug? a. "Are you taking Vitamin C or B? b. "Do you have any allergy to sulfa drugs?" c. "Can you swallow pills pretty easily?" d. "Do you have insurance to cover this drug?"

ANS: B Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should not be given to those who have an allergy to sulfa and sulfa drugs to prevent a hypersensitivity reaction.

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."

ANS: C Clients who have cirrhosis due to addiction may have alienated relatives over the years because of substance abuse. The nurse would assist the client to identify a friend, neighbor, clergy/spiritual leader, or group for support. The nurse would not minimize the patient's concerns. Attending AA may be appropriate, but this response doesn't address the client's concern. "Making peace" with the client's family may not be possible. This statement is not client-centered.

The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? a. Positive Murphy sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn disease. A positive Murphy sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds is not commonly found with Crohn disease. Nightly worsening of abdominal cramping is not consistent with Crohn disease.

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? a. "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." b. "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." c. "Let's talk to the ostomy nurse about options for ostomy supplies and dress styles." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

ANS: C The ostomy nurse is a valuable resource for patients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice

ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup [240 mL] of bean soup) would be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.

The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.

ANS: D For safety, the patient would void just before a paracentesis to prevent bladder damage to the procedure. The primary health care provider would have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table.

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? a. Consuming too much fruit b. Consuming fried or pickled foods c. Consuming dairy products d. Consuming raw seafood

ANS: D Raw seafood is often contaminated and unless cooked can would most likely cause gastroenteritis. Any of the other food can also become contaminated if not stored properly or contaminated by workers/cooks who contaminate these foods.