NCLEX Review: CH 22 and 23

A nurse is providing teaching to a patient who is to undergo bariatric surgery. Which of the following statements, if made by the nurse, is incorrect? 1) "Studies have shown that your diabetes may resolve after this surgery." 2) "Yes, adolescents qualify for this surgery, but they are carefully selected." 3) "This surgery is performed on out-patient basis, but you will remain in the clinic for monitoring for 4-6 hours." 4) "You may need counseling, education, and evaluation for 6-12 months before your surgery."

3) Incorrect This is not an outpatient procedure, and average post-op stay is 4 days, or 23-72 hours if done laparoscopically.

Two nursing students are studying gastric cancer. Which of the following statements by student 1 is incorrect? 1) "Pain relieved by antacids may be one of the first symptoms of gastric cancer." 2) "A diet high in smoked, salted, or pickled foods may contribute to gastric cancer." 3) "Early tumors are usually palpable, and physical examination is important in the detection of gastric cancer." 4) "There may be palpable nodules around the umbillicus called Sister Mary Joseph's nodules, and are usually an ominous finding."

3) Incorrect. Early tumors are usually not detectable by palpation, and physical examination is usually not helpful in detecting gastric cancer.

Four patients are visiting the clinic. Which of the following does the nurse suspect to be at the highest risk for gastric cancer? A) The 53 year old African American woman with diabetes type I B) The 62 year old Japanese male who says he eats many pickled and salted foods C) The 82 year old Hispanic male with a history of HTN D) The 43 year old female with a history of acute glomerulonephritis

Answer: B. A diet high in salted, pickled, or smoked foods and low in vegetables and fruits seems to be a significant risk factor for gastric cancer. Other risk factors include things that cause chronic inflammation of the stomach such as H. pylori infection, smoking, gastric ulcers, etc. HTN, diabetes, and acute glomerulonephritis are not directly associated with this cancer.

The patient arrives to the weight loss clinic asking you about Bariatric Surgery. The patient has a BMI of 36 and has a hx of DM, HTN, dyslipidemia, sleep apnea. She tells you that she is worried that she will have a heart attack like her mother. Which of the following statements would the nurse make first? A) I'm sorry, but I can already tell you that you do not weigh enough to be a candidate for surgery B) Do you have a family history of stroke as well? C) What methods have you tried to lose weight before? D) What medications are you taking?

Answer: C. In order to determine if this client might be a candidate for bariatric surgery, this client would have had to try other methods to lose weight and failed. This client has a high enough BMI with comorbidities in order to be eligible for bariatric surgery. Knowing a family history of stroke would be good to know, but not necessary. Medications is not the priority question

Which of the following findings would the nurse expect to see in the client who has undergone bariatric surgery? A) Hyperkalemia B) Hyponatremia C) Hypercalcemia D) Hypomagnesemia

Answer: D. This client would most likely have too little magnesium d/t decreased intake and decreased ability to absorb nutrients Symptoms of hypomagnesemia include muscle cramps, muscle pain, constipation, HA, insomnia and hyperactivity. Patients who have undergone bariatric surgery are at a high risk for nutritional deficiencies and should be monitored for imbalances. Hyperkalemia and hypercalcemia would not be expected. Hyponatremia, although possible, is much less likely than hypomagnesemia.

Which of the following diagnostics is used to identify malignant cells associated with esophageal cancer? a) Positron emission tomography (PET) b) Endoscopic ultrasound c) Magnetic resonance imaging (MRI) d) Computed tomography (CT)

a)

A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition? a) Give high-protein, semiliquid foods b) Encourage small, frequent meals c) Give liquid supplements for meals d) Provide oral liquids through a straw

a) A major goal for a client with esophageal cancer is adequate or improved nutrition and eventually stable weight. Because he has difficulty in swallowing, the nurse should ensure that the client receives soft foods or high-calorie, high-protein semiliquid foods to get improved nutrition. Providing oral liquids alone will not provide improved nutrition. Using a straw leads to bloating and should be avoided. Providing liquid supplements are used in between meals, not as meals. Encouraging small, frequent meals will give improved nutrition to a client who does not have any difficulty in swallowing.

A client with oral cancer informs the nurse that he has been experiencing dryness of the mouth. The best action of the nurse is to a) Provide a humidifier for the client to use while sleeping. b) Ensure that the client maintains a fluid intake of 2000 mL per day. c) State, "This is a normal consequence of oral cancer." d) Allow the client to continue with his usual diet.

a) Dryness of the mouth (xerostomia) is a frequent sequeala of oral cancer. While explaining this to the client provides information, it does nothing to help solve the problem. The nurse should encourage this client to increase intake of fluids to 2000 to 3000 mL per day. Providing a humidifier will assist in moisturizing the oral cavity. The client needs to be instructed to avoid dry, bulking, and irritating foods and fluids

Which of the following is a true statement regarding gastric cancer? a) Most patients are asymptomatic during the early stage of the disease. b) Most cases are discovered prior to metastasis. c) The prognosis for gastric cancer is good. d) Women have a higher incidence of gastric cancer.

a) Most patients are asymptomatic during the early stage of the disease. Men have a higher incidence of gastric cancer. The prognosis is poor because the diagnosis is usually made late because most patients are asymptomatic during the early stage. Most cases of gastric cancer are discovered only after local invasion has advanced or metastases are present

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours? a) 160 to 200 mL b) 20 to 40 mL c) 80 to 120 mL d) 50 to 75 mL

c)

A patient has just received education regarding what to expect following a surgical resection of the esophagus. He is recapping what he knows, and the nurse must correct him if he makes which of the following statements? 1) "I will have a permanent NG tube after this surgery and will be taught how to properly care for myself." 2) "After each meal, I must remain upright for at least 2 hours." 3) "I may be prescribed Metoclopramide (Reglan) to promote gastric motility." 4) "I need to avoid supplements like Boost and Ensure to avoid something called 'dumping syndrome'."

1) Incorrect The patient will not have an NG tube permanently. The NG tube will be removed in approximately 5-7 days.

Which of the following signs and symptoms may be present in a patient with cancer of the esophagus? Select all that apply 1) dysphagia with both solids and liquids 2) painful swallowing 3) chronic dry cough 4) hiccups 5) progressive weight loss

1, 2, 4, 5 3: Chronic dry cough is not present in a patient with esophageal cancer. Other symptoms may include: foul breath, possible hemorrhage, difficult swallowing, regurgitation of food and saliva, substernal pain, respiratory difficulty.

Which of the following patients does NOT qualify for bariatric surgery? Select all that apply 1) A 34 year-old mother of twins who has a BMI of 35 with no comorbidities. 2) A 25 year-old male, 5'9", who weighs 315 lb., who has tried Weight Watchers for 2 1/2 years with no success. 3) A 66 year-old female who is 120 lb. overweight with early-onset, quickly progressing Alzheimer's. 4) A 54 year-old male with a BMI of 42 with no comorbidities and fresh tract marks on his bilateral upper extremities. 5) A 31 year-old female with Bipolar Depression who compliantly takes Latuda daily and works as an elementary school teacher.

1, 3, 4 1: Correct. This patient does not qualify. Patients with no comorbidities must have a BMI over 40. 2: Incorrect. This patient qualifies. He is well over 100 lb. overweight for his height, and he has tried a non-surgical form of weight loss with no success. 3. Correct. This patient does not qualify. Patient who are suspected to not be able to adhere to post-op care, follow-up visits, or medical management are not good candidates. 4. Correct. This patient does not qualify. This patient is clearly an IV drug user, and patients with current drug or alcohol use do not qualify. 5. Incorrct. This patient qualifies. This patient does have a psychiatric illness, but it is clearly controlled. There is also no indication in this question that her psychiatric illness is severe.

A nursing instructor is teaching her students about the nursing process regarding a patient undergoing gastric surgery. Which of the following statements, if made by the instructor, is incorrect? Select all that apply 1) "If any NG drainage is observed after surgery, the amount should be recorded and the physician should be notified." 2) "After bowel sounds return, your patient will gradually work towards 6-8 small meals a day with fluids between the meals to prevent dumping syndrome." 3) "Your patient will need to understand that after gastrectomy, he/she will likely need monthly injections of vitamin B12." 4) "Your patients should assume a high-Fowler's positioning during and following meals." 5) "Fats can be eaten as tolerated, but carbohydrate intake should be low, and concentrated sources of carbs should be avoided."

1, 4 1: Incorrect; normally, the amount of NG drainage after gastric surgery is minimal, but there will be SOME drainage. 4: Incorrect; the patient should assume a low-Fowler's position while eating and the patient should like down for 20-30 minutes following meals.

Which of the following pieces of information is incorrect regarding nursing care of the patient undergoing a neck dissection? 1) Chyle fistula and nerve injury are two potential postoperative complications that may develop. 2) High epigastric pain is a common postoperative complication that may be treated with acetaminophen or opioids, but not NSAIDS. 3) Medium-chain fatty acids may be used as part of treatment for a Chyle fistula. 4) If serosanginous drainage exceeds 120mL in the first 24 hours, this should alert the nurse to a problem of Chyle fistula or hemorrhage.

2) Incorrect High epigastric pain and discomfort can be signs of impending rupture and must be reported.

The nurse practitioner counsels a patient about being a candidate for bariatric surgery. The patient is 5'4" tall and weighs 300 pounds (IBW is 125 lbs). The nurse tells the patient that, based on the average weight loss after surgery, she should expect to eventually weigh: 1) 180 lb 2) 210 lb 3) 120 lb 4) 160 lbe

3) 120 lb Research has shown that the average weight loss after bariatric surgery is about 60% of previous body weight. If the patient weighed 300 lbs, 60% would be 180 lbs. Subtract: 300 - 180 = 120 lbs.

A patient has undergone a radial neck dissection. His skin graft is pale. This indicates which of the following? 1) Infection 2) Possible necrosis 3) Arterial thrombosis 4) Venous congestion

3) Arterial thrombosis

A 64 year-old male is undergoing examination and testing for suspected esophageal cancer. Which of the following tests most often confirms the diagnosis of esophageal cancer? 1) MRI (Magnetic Resonance Imaging) 2) CT Scan (Computed Tomography Scan) 3) EGD with Biopsy and Brushings 4) Endoscopic Ultrasound

3) EGD with Biopsy and Brushings

The nurse understands that morbid obesity can lead to which of the following health problems? SATA: A) COPD B) Heart disease C) Osteoarthritis D) Gallbladder disease E) Paralytic ileus

Answer: BCD. It is also linked to increased risk of diabetes, hypertension, sleep apnea, and certain cancers

A nursing instructor is teaching her students about nursing management involved in the care of patients with esophageal cancer. Which of the following statements, if made by the instructor, is incorrect? 1) "A high-calorie, high-protein diet can be encouraged to promote weight gain in these often malnourished patients." 2) "We are concerned about the patient developing aspiration pneumonia about surgical resection of the esophagus, so we need to regularly monitor the patient's temperature and have them change positions." 3) "A small amount of drainage from the cervical neck wound, usually saliva, is common in the first 24-48 hr. post-op and requires no intervention except monitoring." 4) "Cardiac complications following esophageal surgery may include atrial fibrillation, and heart sounds should be auscultated regularly."

3) Incorrect Drainage from the cervical neck wound, usually saliva, is evidence of an early esophageal leak. This is usually treated by placing the patient NPO and providing parenteral or enteral support.

A 75-year old patient has had symptoms of GERD, like frequent heartburn, for about 6 months. He is diagnosed with Barrett's esophagus. An EGD is performed and reveals significant cellular changed in the esophageal lining. Which of the following treatments does the nurse expect this patient to receive? 1) Follow-up EGD in 6-12 months 2) Follow-up EGD in 2-5 years 3) PDT (Photodynamic therapy) 4) Diet and lifestyle modification before attempting therapy

3) PDT will likely be prescribed for this patient due to his age over 70 years old. Cellular changes are significant in this patient, so a follow-up EGD is not sufficient for treatment. Diet and lifestyle modifications will not fix cellular damage to the esophageal lining.

A patient is being provided education regarding life after bariatric surgery. Which statement, if made by the patient, MOST indicates the need for further teaching? 1) "After my stomach starts moving around again after surgery, I can have six small feedings a day with a total of 600-800 calories a day.. wait, am I going to starve?!" 2) "Oh, I can have two protein snacks a day? That's good, maybe I won't starve." 3) "I won't be able to exercise for 4-6 weeks following my surgery... I'm going to get fat again." 4) "I need to avoid beer, apple juice, and Pepsi. Those are all my favorite drinks... are you kidding me?"

3) This is incorrect. Patients are encouraged to walk for at least 30 minutes per day following bariatric surgery. The other questions indicate correct understanding of by the patient, but the patient is unsatisfied with what he/she has learned. These (1,2,4) do not represent as severe of a learning deficit as the statement in answer 3 does.

A nursing instructor is teaching a group of students how to recognize individuals at high risk for esophageal cancer. Which of the following statements, if made by a student, requires correction by the instructor? 1) "People with GERD and Barrett's esophagus are more at risk for esophageal cancer." 2) "A person who abuses alcohol or uses tobacco is at risk for developing esophageal cancer." 3) "People who spend a great amount of time around pesticides and rubber products may be at risk for developing esophageal cancer." 4) "As long as the patient avoids chronic ingestion of hot liquids and foods and avoids beer and other forms of alcohol, nutrition does not play a significant role in the development of esophageal cancer."

4) Incorrect In addition to alcohol and chronic ingestion of hot liquids and foods, consuming cured meats and other dietary deficiencies can play a role in the development of esophageal cancer.

Following bariatric surgery, a patient in room 211 is complaining of a moderate headache, muscle cramps in his bilateral lower extremities, and inability to pass stool. Prior to reviewing this patient's lab results, the nurse expects which of the following values to be decreased? 1) Potassium 2) Zinc 3) B-coretene 4) Magnesium

4) Magnesium Additional signs of magnesium deficiency include: muscle pain, insomnia, anxiety, and hyperactivity. Pulled from table 23-6, page 645.

The nurse is taking care of the patient just diagnosed with gastric cancer. Which date would the nurse expect to possibly see upon examination? SATA: A) Sister Mary Joseph's nodules B) Abdominal pain C) Bloody diarrhea D) Weight gain E) Dyspepsia

Answer: A, B, and E. Sister Mary Joseph's nodules are palpable nodules around the umbilicus which are a sign of a GI malignancy, typically gastric cancer. Abdominal pain, dyspepsia, nausea and vomiting, bloating after meals, loss of appetite, early satiety and weight loss are also possible signs associated with gastric cancer (very similar to PUD) Weight gain and bloody diarrhea are not associated with this condition.

A health care provider counsels a patient about bariatric surgery. He recommends the Roux-en-Y gastric bypass. The nurse explains to the patient that this procedure involves which of the following? a) Gastroplasty with a vertical band allowing for a pouch with a 15 to 20 mL capacity b) Separation of the jejunum with an anastomosis c) Biliopancreatic diversion with a duodenal switch d) Gastric banding that incorporates a prosthetic device to restrict oral intake

b) The Roux-en-Y gastric bypass is recommended for long-term weight loss because it uses a combined restrictive and malabsorptive procedure. Refer to Figure 23-3 (A to D) in the text.

Amanda Ford, a 53-year-old actress, is being seen by a physician in your oncology group due to her oral cancer. In the initial stages of diagnosis, she is frightened about her treatment and subsequent prognosis. She asks where oral cancer typically occurs. What is your response? a) Roof of the mouth b) Base of the tongue c) Floor of the mouth d) Don't worry, you've got a very talented surgeon!

c)

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is: a) Teach the client exercises for the neck and shoulder area to perform 1 day after surgery. b) Provide oxygen without humidity through the tracheostomy tube. c) Make a notation on the call light system that the client cannot speak. d) Encourage the client to position himself on his side.

c) Explanation: The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.

Morbid obesity is defined as being how many pounds over the person's ideal body weight? a) 90 b) 75 c) 50 d) 100

d) Morbid obesity is a term applied to people who are more than two times their ideal body weight or whose body weight index (BMI) exceeds 30 kg/m2. Another definition of morbid obesity is body weight that is more than 100 pounds greater than the ideal body weight.

Which of the following bariatric surgical procedures is optimal for long-term weight loss? a) Gastric ring application b) Vertical banded gastroplasty c) Jejunoileal bypass d) Roux-en-Y

d) The Roux-en-Y gastric bypass is the recommended procedure for long-term weight loss. In this procedure, a horizontal row of staples creates a stomach pouch with a 1-cm stoma that is anastomosed with a portion of distal jejunum, creating a gastroenterostomy. In vertical banded gastroplasty, a double row of staples is applied vertically along the lesser curvature of the stomach, beginning at the angle of His. Over time, the gastric restriction may fail. Application of a silicone ring to the fundus of the stomach may fail. The first surgical procedure to treat morbid obesity was the jejunoileal bypass. This procedure, which resulted in significant complications, has been largely replaced by gastric restriction procedures.