Adult Health Exam 3

After assessing a client with peritonitis, how would the nurse most likely document the client's bowel sounds?

Absent Explanation: Since lack of bowel motility typically accompanies peritonitis, bowel sounds are absent. Therefore, the nurse will not observe mild, high-pitched, or hyperactive bowel sounds.

Which of the following is the primary function of the small intestine?

Absorption Explanation: Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms Explanation: The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

A nurse plans care for a client who is post op bariatric surgery. Which nursing diagnosis will be the priority?

Acute pain related to surgical procedure Explanation: When determining the priority of nursing diagnoses, the nurse must recognize that airway, breathing, and circulation come first always. The client who is in acute pain will be unable to take deep breaths and is at increased risk for pulmonary complications. Acute pain is the priority nursing diagnosis. The other nursing diagnoses are appropriate for this client; however, they are not the priority.

A nurse is caring for a client admitted with symptoms of an anorectal infection; cultures indicate that the client has a viral infection. The nurse should anticipate the administration of what drug?

Acyclovir Explanation: Acyclovir (Zovirax) is often given to clients with viral anorectal infections. Doxycycline (Vibramycin) and penicillin (penicillin G) are drugs of choice for bacterial infections. Metronidazole (Flagyl) is used for other infections with a bacterial etiology; it is ineffective against viruses.

A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of?

Adhere to the medication regimen. Explanation: All of the teaching points are important but the most important is emphasizing the strict adherence to the medication regimen because glaucoma cannot be cured but its progression can be slowed.

When preparing a client for a hemorrhoidectomy, the nurse should take which action?

Administer an enema as ordered. Explanation: When preparing a client for a hemorrhoidectomy, the nurse should administer an enema, as ordered, and record the results. After surgery, the client may require antibiotics and analgesics.

The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus?

Administer prescribed metoclopramide. Explanation: Metoclopramide (Reglan) is administered to increase peristalsis of the feeding tube into the duodenum. Placing the client on the right side, not the left side, helps to facilitate movement and placement. Having the client swallow or even to drink water facilitates placement of the tube past the epiglottis, not into the duodenum.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

Administering morphine I.V. as ordered Explanation: The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

The nurse reviews data collected during a health history with a client. Which finding(s) does the nurse identify that increases the client's risk of developing cholesterol gallbladder stones? Select all that apply. Age 45 Female Vegan eating plan Body mass index 23 History of appendicitis

Age 45 Female Explanation: Cholesterol stones account for most of the cases of gallbladder disease in the United States. Cholesterol, which is a normal constituent of bile, is insoluble in water. People affected by this type of gallbladder stone are usually older than 40 years. Two to three times more women than men develop cholesterol stones. Cholesterol gallbladder stones are not associated with a vegan eating plan. This type of gallbladder stone is associated with obesity. There is no association between cholesterol gallbladder stones and a history of appendicitis.

An older client underwent a lumpectomy for a breast lesion that was determined to be malignant. Which factors in the client's history may have increased the risk of breast cancer? \All options are correct. not giving birth obesity increased age

All options are correct. Explanation: Being female, being older than 50 years of age, and having a family history of breast cancer are the most common risk factors. Additional factors include obesity, and having no children or having children after 30 years of age.

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching?

"A hepatitis B immunization is given to infants and children." Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age.

A nurse is performing an eye examination. Which question would not be included in the examination?

"Are you able to raise both eyebrows?" Explanation: Asking to raise both eyebrows is a test for cranial nerve VII, the facial nerve, and would not be included in an eye assessment.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins?

Amylase pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3-6 hr following the onset of acute pancreatitis. The amylase level peaks in 20-30hr and returns to the expected reference range within 2-3 days.

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect?

Anorexia Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A client with a gastrointestinal condition asks why the mouth needs to be examined. Which response will the nurse make?

"Changes in the mouth can help explain why your condition is occurring." Explanation: A complete assessment of the oral cavity is essential because many disorders, such as cancer, diabetes, and immunosuppressive conditions resulting from medication therapy or acquired immunodeficiency syndrome, may be manifested by changes in the oral cavity, including stomatitis. Assessment of the mouth is not done because it is the body part least examined. It is not assessed because it is a part of every assessment. The nurse has no way of knowing if the client's gastrointestinal problem is in the client's mouth.

A nurse cares for a client who wants to know more information about bariatric surgery. The client asks the nurse, "What weight loss can I expect?" What is the nurse's best response?

"Expect to lose 10-35% of total body weight 2 to 3 years postoperatively." Explanation: When discussing weight loss expectations with the client, the nurse should let the client know to expect to lose 10-35% of total body weight 2 to 3 years postoperatively. The client may lose a large amount of weight the first month after surgery; however, this is not generally quantified with exact numbers or ranges.

The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client makes which statement?

"I have learned some relaxation strategies that decrease my stress." Explanation: The nurse assists the client to identify stressful or exhausting situations. A hectic lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings along with the regular administration of medications. The client may benefit from regular rest periods during the day, at least during the acute phase of the disease. Biofeedback, hypnosis, behavior modification, massage, or acupuncture may be helpful.

A client with an H. pylori infection asks why bismuth subsalicylate is prescribed. Which response will the nurse make?

"It aids in the healing of the stomach lining." Explanation: Bismuth subsalicylate suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers. It does not affect digestion, enhance the function of the pyloric sphincter, or propel food from the stomach into the duodenum.

A nurse cares for a client who is obese. The health care provider prescribes orlistat in an effort to help client lose weight, along with diet and exercise. When teaching the client about this medication, what will the nurse include?

"It binds with enzymes to help prevent digestion of fat." Explanation: Orlistat (Xenical) works to bind to gastric and pancreatic lipase to prevent the digestion of 30% of ingested fat, thereby decreasing caloric intake.

A nurse prepares community teaching on healthy lifestyle modifications to a group of older adults. When discussing obesity rates of older adults in comparison with the rest of the population, what will the nurse include?

"Older adults have a slightly higher prevalence of obesity in comparison to the general population." Explanation: Older adults have a slightly higher prevalence of obesity when compared to the general population.

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

"The laxative helps eliminate the barium" The nurse's statement that the laxative will help eliminate the barium is appropriate and provides the client with the reason for the laxative.

A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching?

"The procedure can determine how well the lower part of your esophagus works" An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.

A client is scheduled for a Roux-en-Y bariatric surgery. When teaching the client about the surgical procedure, which statement will the nurse use?

"The stomach is stapled to create a very small pouch and part of the small intestine is rerouted." Explanation: In Roux-en-Y bariatric surgery, a horizontal row of staples across the fundus of the stomach creates a pouch with a capacity of 20 to 30 mL. The jejunum is divided distal to the ligament of Treitz, and the distal end is anastomosed to the new pouch. The proximal segment is anastomosed to the jejunum.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment?

"The tube allows the gastrointestinal tract to rest." Explanation: Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

A nurse cares for a client with a BMI of 36 kg/m2 and nonalcoholic fatty liver disease. The client asks the nurse if he is a candidate for bariatric surgery. How should the nurse respond to the client?

"Yes, your BMI and chronic condition meets the criteria for bariatric surgery." Explanation: The client's BMI of > 35 kg/m2 and a more severe obesity-associated comorbid condition, makes the client a candidate for bariatric surgery.

A client who is 6 months postoperative bariatric surgery tells the nurse, "I hate what my body looks like now. All these skin folds really bother me." What is the nurse's best response?

"You are not alone in having these feelings." Explanation: A client who is postoperative from bariatric surgery may share that they are dissatisfied with their appearance, often due to loose skin folds from excessive weight loss. It is the nurse's role to validate the client's feelings and to make sure the client understands that these feelings are normal. Asking the client why he or she is dissatisfied put the client in a defensive space and is not therapeutic. The client needs validation for his or her feelings; not being told that he or she can change. This may worsen the client's body image.

A nurse researches the cost and financial impact of obesity in America. What is the annual health care cost tied to obesity?

$147 billion Explanation: The estimated annual health care costs in America tied to obesity is $147 billion.

A nursing student is preparing a teaching plan about peptic ulcer disease. The student knows to include teaching about the percentage of clients with peptic ulcers who experience bleeding. The percentage is

15% Explanation: Fifteen percent of clients with peptic ulcer experience bleeding.

It is determined that a patient is legally blind and will be unable to drive any longer. Legal blindness refers to a best-corrected visual acuity (BCVA) that does not exceed what reading in the better eye?

20/200 Explanation: Legal blindness is a condition of impaired vision in which a person has best corrected visual acuity that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less (Prevent Blindness America, 2012).

A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk?

23 Explanation: Patients with a BMI of 23 would have the lowest risk for health problems. Those with a BMI of 18 might have the increased risk associated with poor nutritional status. Those with a BMI of 28 are considered overweight, and those with a BMI of 30 to 39 are considered obese. Both of these groups have an increased risk for health problems.

Calculate the BMI of a client who is 6 feet 1 inch tall and weighs 200 pounds. Round to one decimal.

26.4 Explanation: To calculate BMI, multiply weight in pounds by 703 and then divide that by height in inches squared

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 Explanation: Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance.

When completing a nutritional assessment of a patient who is admitted for a GI disorder, the nurse notes a recent history of dietary intake. This is based on the knowledge that a portion of digested waste products can remain in the rectum for how many days after a meal is digested?

3 days Explanation: As much as 25% of the waste products from a meal may still be in the rectum 3 days after a meal is ingested.

A client weighing 165 lb. (75 kg) is being treated for acute gastritis. Which amount of urine output for 4 hours would indicate an adequate fluid balance if the output should be 1 mL/kg/hour?

300 Explanation: To determine the client's weight in kg, divide the weight in lb. by 2.2 or 165 / 2.2 = 75 kg. Fluid balance for this client would be 75 mL/hr. For four hours, the client's output would need to be 300 mL as an indication of fluid balance.

A client weighs 215 lbs and is 5' 8" tall. The nurse calculate this client's body mass index (BMI) as what?

32.7 Explanation: Using the formula for BMI, the client's weight in pounds (215) is divided by the height in inches squared (68 inches squared) and then multiplied by 703. The result would be 32.7.

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?

4 Explanation: Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.

The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform?

Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye Explanation: Punctal occlusion is done by applying gentle pressure to the inner canthus of each eye for 1 to 2 minutes immediately after eye drops are instilled. The nurse does not apply pressure to the eyeball when administering medications. The lower eyelid is held down to expose the conjunctival sac. The other action described will not aid in the retention or absorption of medication.

The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.

6 Explanation: Step 1:2 × 8 oz = 16 oz Step 2:1 oz : 30 mL :: 16 oz : X mL X = 480 mL Step 3: 480 mL / 80 mL = 6 hours

A patient is receiving pharmacologic therapy with ursodeoxycholic acid or chenodeoxycholic-cholic acid for treatment of small gallstones. The patient asks the nurse how long the therapy will take to dissolve the stones. What is the best answer the nurse can give?

6 to 12 months Explanation: Ursodeoxycholic acid (UDCA [Urso, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol (Karch, 2012). Six to 12 months of therapy is required in many patients to dissolve stones, and monitoring of the patient for recurrence of symptoms or the occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?

80 to 120 mL Explanation: Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.

A nurse is preparing a presentation for a local community group of older adults about colon cancer. What would the nurse include as the primary characteristic associated with this disorder?

A change in bowel habits Explanation: Although abdominal distention and blood in the stool (frank or occult) may be present, the chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Abdominal pain is a late sign.

A patient is scheduled for a Billroth I procedure for ulcer management. What does the nurse understand will occur when this procedure is performed?

A partial gastrectomy is performed with anastomosis of the stomach segment to the duodenum. Explanation: A Billroth I procedure involves removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. A vagotomy severs the vagus nerve; a Billroth I procedure may be performed in conjunction with a vagotomy. If the remaining part of the stomach is anastomosed to the jejunum, the procedure is a Billroth II.

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply. Strict bedrest Daily weights Daily transparent dressing changes Intake and output monitoring Calorie counts for oral nutrients

Daily weights Intake and output monitoring Calorie counts for oral nutrients Explanation: For the client receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the client is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the client's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the client's ability to maintain muscle tone. Strict bedrest is not appropriate.

A nurse on a mental health unit is admitting a client who has generalized anxiety disorder. Which of the following tasks should the nurse plan to include in the orientation phase of the relationship between the client and the nurse?

Develop a contract with the client about how private information will be handled The nurse should develop a contract with the client about how confidential information will be handled in the orientation phase of the nurse-client relationship. This phase sets the tone for the overall interaction and defines the primary purpose of the relationship. The major task of the nurse during this phase is to help the client clarify the current problem.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings?

Diaphoresis The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

Which is the primary symptom of achalasia?

Difficulty swallowing Explanation: The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

The nurse is preparing to administer ondansetron to an older adult client. Which safety warning(s) should the nurse consider when administering the medication? Select all that apply. Do not use if the client has a heart block or prolonged QT interval. It increases sedation if used with opiates. Emphasize prevention. The client must take consistently to prevent nausea and vomiting. Explain that it must be started before travel to be effective. Explain that there is a risk for dehydration.

Do not use if the client has a heart block or prolonged QT interval. It increases sedation if used with opiates. Emphasize prevention. The client must take consistently to prevent nausea and vomiting. Explanation: Not using the medication if the client has a heart block or prolonged QT interval, the fact that the medication increases sedation if used with opiates, and emphasizing prevention (the client must take the medication consistently to prevent nausea and vomiting) are all safety warnings that the nurse should consider when administering ondansetron. Ondansetron is not given to relieve motion sickness; therefore, beginning the medication before travel is not applicable. Prochlorperazine, not ondansetron, may increase dehydration in older adults.

Which tube is a nasoenteric feeding tube?

Dobbhoff Explanation: The Dobbhoff tube is a nasoenteric feeding tube. Nasogastric tubes include Levin, a gastric sump, and Sengstaken-Blakemore tubes.

The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching?

Drink 8 to 10 glasses of fluid daily. Explanation: The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client should include unprocessed bran in the diet because it adds bulk, and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.

What information should the nurse include in the teaching plan for a client being treated for diverticulosis?

Drink at least 8 to 10 large glasses of fluid every day Explanation: The nurse should instruct a client with diverticulosis to drink at least 8 to 10 large glasses of fluid every day. The client should include unprocessed bran in the diet because it adds bulk, and should avoid the use of laxatives or enemas except when recommended by the physician. In addition, regular exercise should be encouraged if the client's current lifestyle is somewhat inactive.

Clients with Type O blood are at higher risk for which of the following GI disorders?

Duodenal ulcers Explanation: Familial tendency also may be a significant predisposing factor. People with blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB. Blood type is not a predisposing factor for gastric cancer, esophageal varices, and diverticulitis.

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?

Dysphagia Explanation: Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).

The nurse is caring for a client with suspected chronic pancreatitis. Which diagnostic test or imaging does the nurse recognize as the most useful in diagnosing this condition?

ERCP Explanation: The ERCP is the most useful study in the diagnosis of chronic pancreatitis. The other answer choices may be used; however, these are not the most useful in the diagnosis of chronic pancreatitis.

The nurse cares for a client with gallstones that need to be removed but is not a surgical candidate or endoscopic candidate. What procedure does the nurse recognize as being a possible treatment option for the client?

ESWL Explanation: Extracorporeal shock wave therapy, (ESWL) also known as lithotripsy, uses shock waves to break up gallstones for their removal and does not involve surgery or endoscopy. The other answer choices are performed by endoscopy.

The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation should the nurse make to the client?

Eat several small meals daily spaced at equal intervals. Explanation: The client with dumping syndrome should consume small meals at intervals to reduce symptoms. The client should not consume fluids with meals. Carbohydrates should be limited and sitting upright does not relieve the symptoms.

Which of the following is the correct advice regarding food for a patient who underwent a cataract surgery?

Eat soft, easily chewed foods. Explanation: The nurse should advise patients recovering from cataract surgery to eat soft, easily chewed foods until healing is complete to avoid tearing from excessive facial movements. Eating spinach or collard greens two to four times per week reduces the risk of macular degeneration and increasing the intake of vitamins A and C is essential for preventing cataracts; however, these have no implications on recovery from cataract surgery.

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder?

Edema and inflammation Explanation: Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply. Elevate the upper body on pillows. Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid. Elevate the head of the bed on 6- to 8-inch blocks. Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. Avoid beer, especially in the evening.

Elevate the upper body on pillows. Elevate the head of the bed on 6- to 8-inch blocks. Avoid beer, especially in the evening. Explanation: Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?

Elevated urine amylase levels Explanation: Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?

Encourage plenty of fluids. Explanation: The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing the therapeutic regimen. What would not be included?

Encourage the client to avoid exercise. Explanation: Activity promotes healing and normal stool patterns. Proper cleansing prevents infection and irritation. Sitz baths promote healing, decrease skin irritation, and relieve rectal spasms. Encouragement promotes compliance with therapeutic regimen and prevents complications.

A health care provider suspects that a client has peptic ulcer disease. With which diagnostic procedure would the nurse most likely prepare to assist?

Endoscopy Explanation: Barium study of the upper GI tract may show an ulcer; however, endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Endoscopy may reveal lesions that, because of their size or location, are not evident on x-ray studies. 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.

The nurse has taken shift report on a group of clients and has been told that one client has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the client?

Ensure adequate lighting in the client's room. Explanation: The nurse should provide adequate lighting in the client's room, as the rods are mainly responsible for night vision or vision in low light. If the client's rods are impaired, the client will have difficulty seeing in dim light. The cones in the eyes provide best vision for bright light, color vision, and fine detail.

A client has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. What is the nurse's best response to this change in health status?

Ensure that none of the client's visitors have an infection. Explanation: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the client's immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.

An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom?

Esophageal tumor Explanation: Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer

A client in the emergency room was involved in a motor vehicle accident which caused blunt facial trauma, especially to the orbit of the skull. Which bones are in danger of fracture in this type of injury? Select all that apply. Ethmoid Frontal Stapes Lacrimal Mastoid

Ethmoid Frontal Lacrimal Explanation: The eyeballs are globes located in a protective bony cavity or orbit of the skull. The frontal, maxillary, zygomatic, sphenoid, ethmoid, lacrimal, and palatine bones form the walls of the orbit. The mastoid bone is part of the skull behind the ear. The stapes bone is in the middle ear.

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?

Excess fluid volume Explanation: The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.

Which medication is classified as a histamine-2 receptor antagonist?

Famotidine Explanation: Famotidine is a histamine-2 receptor antagonist. Lansoprazole and esomeprazole are proton pump inhibitors (PPIs). Metronidazole is an antibiotic.

A client has been taking famotidine at home. What teaching should the nurse include with the client?

Famotidine will inhibit gastric acid secretions. Explanation: Famotidine is useful for treating and preventing ulcers and managing gastroesophageal reflux disease. It functions by inhibiting the action of histamine at the H-2 receptor site located in the gastric parietal cells, thus inhibiting gastric acid secretion. Famotidine will not neutralize acid in the stomach, but inhibits acid secretion. Famotidine will not shorten digestion time and will not improve food mixing with gastric secretions.

A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia?

Fear of eating Explanation: Dumping syndrome is an unpleasant set of GI and vasomotor symptoms that commonly occur in clients who have had bariatric surgery. The symptoms are so unpleasant that the client may develop a fear of eating, leading to anorexia.

Postoperatively, a client with a radical neck dissection should be placed in which position?

Fowler Explanation: The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position also promotes expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

Postoperatively, a client with a radical neck dissection should be placed in which position?

Fowler Explanation: The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position expands the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?

Frequent changes of positions Explanation: Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first?

Further investigate the initial complaint. Explanation: While fatty foods can cause discomfort similar to chest pain, the nurse must fully assess all the client's symptoms. Investigation of chief complaint begins with a complete history. The underlying cause of pain influences the characteristics, duration, pattern, location, and distribution of pain.

A nurse cares for a client with obesity. Which medication that the client takes may be contributing to the client's obesity?

Gabapentin Explanation: Gabapentin (Neurontin) is an anticonvulsant medication which promotes weight gain. The other answer choices are medications which promote weight loss, not gain.

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority? Pain Nausea Gag reflex Level of consciousness

Gag reflex The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed.

A nurse is caring for client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use?

Gamma-glutamyl transferase (GGT) The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient?

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely.

Which of the following is the leading cause of blindness in the United States?

Glaucoma Explanation: Glaucoma is one of the leading causes of irreversible blindness in the world and is the leading cause of blindness among adults in the United States.

A client is having an upper endoscopy. Which medication(s) might the nurse provide during the procedure? Select all that apply. Glucagon Atropine Midazolam Metoprolol Anesthetic spray

Glucagon Atropine Midazolam Anesthetic spray Explanation: An upper endoscopy can be used to visualize gastrointestinal structures and identify neoplasms. The client will be given different medications during the test. Glucagon is used to relax smooth muscle. Atropine is used to reduce secretions. Midazolam is used to relieve anxiety and paralyze the gag reflex. Anesthetic spray is used to anesthetize the throat before introducing the endoscope. Metoprolol is a beta blocker and is not used during an upper endoscopy.

Which precautions should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance?

Grasp the siderails when rising to a standing position. Explanation: The nurse should have the client use firm supports, such as siderails, whenever arising. There is no need to limit the client's gaze or head movements. Keeping the eyes closed can exacerbate disorientation.

A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction?

Gray Explanation: A gray-white stool color is common with a biliary obstruction because the stool is no longer colored with bile pigments.

The nurse should monitor for which manifestation in a client who has undergone LASIK?

Halos and glare Explanation: Symptoms of central islands and decentered ablations can occur after LASIK surgery; these include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.

The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?

Hamburger and French fries Explanation: Fatty foods delay stomach emptying (bloating) and can cause symptoms of gastrointestinal upset. Fried and deep fried foods contain elevated amounts of fat. The other options have a lower fat content.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?

Hang a solution of dextrose 10% and water until the new solution is available. Explanation: The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency.

Which of the following precautions should the nurse take when a patient is at risk of injury secondary to vertigo and probable imbalance?

Have the patient sit in a wheelchair when moving. Explanation: The nurse should have the patient sit in a wheelchair when being moved. The patient should restrict movement. The patient should keep his or her eyes open and look at one place to reduce vertigo.

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?

Hematemesis Explanation: 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 client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed?

Hemorrhage Explanation: Signs of hemorrhage following surgery include cool skin, confusion, increased heart rate, labored breathing, and blood in the stool. Signs of penetration and perforation are severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and increased heart rate. Indicators of pyloric obstruction are nausea, vomiting, distended abdomen, and abdominal pain.

A client has undergone enucleation. What complication of enucleation should be addressed by the nurse?

Hemorrhage Explanation: The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting may be common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Hot roast beef sandwich with gravy Explanation: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as roast beef because fatty foods may bring on an episode of cholecystitis.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

Hyperactive Explanation: Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma, 2012).

A nurse working in a cardiac health care office notes increased risk of certain cardiac conditions as a result of obesity. Which conditions can be associated with obesity? Select all that apply. Hypertension Coronary artery disease Heart failure Myocardial infarction Heart murmur

Hypertension Coronary artery disease Heart failure Myocardial infarction Explanation: Various cardiac diseases and conditions may be associated with obesity. These include: hypertension, heart failure, myocardial infarction, and coronary artery disease. Heart murmur is not directly associated with obesity.

An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?

Hypokalemia Explanation: The older client taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the client to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.

The upper eyelid normally covers the uppermost portion of the iris and is innervated by which cranial nerve?

III Explanation: The upper lid is innervated by the oculomotor nerve (CN III). Cranial nerve I is the olfactory nerve, cranial nerve II is the optic nerve, and cranial nerve IV is the trochlear nerve.

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead Explanation: The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.

A client is reporting problems with constipation. What dietary suggestion can the nurse inform the client may help facilitate the passage of stool?

Increase dietary fiber. Explanation: Constipation may result from insufficient dietary fiber and water. A diet low in fiber predisposes people to constipation because the stools produced are small in volume and dry. Increasing the carbohydrate, fat, and protein content will not facilitate the passage of stool.

Place the pathophysiological steps in order of how a client with obesity is at greater risk for venous thromboembolism in comparison to the general population. Impairment of peripheral blood flow Formation of a thrombus Blood stasis Increased adipose tissue

Increased adipose tissue Impairment of peripheral blood flow Blood stasis Formation of a thrombus Explanation: In obesity, an increase in adipose tissue impairs the peripheral blood flow, leading to blood stasis and the formation of a thrombus.

Loud, persistent noise has been found to have which of the following effects on the body? Select all that apply. Increased blood pressure Increased heart rate Dilation of peripheral blood vessels Constriction of peripheral blood vessels Decreased gastrointestinal motility

Increased blood pressure Increased heart rate Constriction of peripheral blood vessels Explanation: Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure and heart rate (because of increased secretion of adrenalin), and increased gastrointestinal activity, well as disturbed patterns of sleep.

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?

Increasing difficulty in swallowing Explanation: The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of?

Increasing fluid intake to prevent dehydration Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply. Inform the client to remain upright for at least 2 hours after meals. Encourage the client to eat later in the day before bedtime rather than early in the morning. Instruct the client to avoid alcohol or tobacco products. Encourage the client to eat frequent, small, well-balanced meals. Instruct the client to eat slowly and chew the food thoroughly.

Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Encourage the client to eat frequent, small, well-balanced meals. Instruct the client to eat slowly and chew the food thoroughly. Explanation: The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.

A client with gastroesophageal reflux disease is scheduled for esophageal manometry. Which information about the test will the nurse review with the client? Select all that apply. Take laxatives for 2 days before the test. Withhold food and fluids until the gag reflex returns. Ingest no food or fluids for 8 to 12 hours before the test. Withhold taking calcium channel blocking medications for 24 to 48 hours. Expect to remain in the testing facility until fully awake from the anesthesia.

Ingest no food or fluids for 8 to 12 hours before the test. Withhold taking calcium channel blocking medications for 24 to 48 hours

A client is scheduled for an upper gastrointestinal barium study. Which teaching will the nurse provide for the client to prepare for this diagnostic test?

Ingest nothing by mouth after midnight. Explanation: An upper GI fluoroscopy delineates the entire GI tract after the introduction of a contrast agent such as barium. To prepare for the test, the client should be instructed to ingest nothing after midnight before the test. Clear liquids are not permitted the morning of the test. Most oral medications are withheld the morning of the test, but not for 24 hours before. There is no reason to avoid products containing aspirin for a week before the test.

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply.

Ingestion of strong acids Irritating foods Overuse of aspirin Explanation: Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. A DASH diet is an acronym for Dietary Approaches to Stop Hypertension, which would not cause gastritis. Participation in competitive sports also would not cause gastritis.

A patient visited a nurse practitioner because he had diarrhea for 2 weeks. He described his stool as large and greasy. The nurse knows that this description is consistent with a diagnosis of:

Intestinal malabsorption. Explanation: Watery stools are characteristic of disorders of the small bowel, whereas loose, semisolid stools are associated more often with disorders of the large bowel. Large, greasy stools suggest intestinal malabsorption, and the presence of mucus and pus in the stools suggests inflammatory enteritis or colitis.

A client presents to the ED reporting a chemical burn to both eyes. Which is the priority nursing intervention?

Irrigate both eyes. Explanation: The eyes should immediately be irrigated to remove the chemical and preserve the eye. If the chemical is allowed to remain on the eye surface, it may cause ulcerations and permanent damage to the eye. It is appropriate to obtain the MSDS and assess the pH of the corneal surface after irrigation has begun. Irrigation should continue until the pH normalizes. Visual acuity can be assessed once the emergent phase is over.

A client comes to the eye clinic for a routine check-up. The client tells the nurse he thinks he is color blind. What screening test does the nurse know will be performed on this client to assess for color blindness?

Ishihara Explanation: Color vision is assessed with Ishihara polychromatic plates. The client receives a series of cards on which the pattern of a number is embedded in a circle of colored dots. The numbers are in colors that color-blind persons commonly cannot see. Clients with normal vision readily identify the numbers. The Jaeger and the Rosenbaum test near vision while the Snellen tests far vision.

The nurse is comparing Crohn's disease (regional enteritis) with ulcerative colitis. Which of the following describes Crohn's disease?

Its course is prolonged and variable Explanation: The course of Crohn's disease is prolonged and variable whereas ulcerative colitis follows a pattern of exacerbations and remissions. In Crohn's disease, bleeding usually does not occur but tends to be mild when it does occur; fistulas are common, and diarrhea is less severe than it is with ulcerative colitis.

Which action should the nurse recommend to a client with blepharitis?

Keep lid margins clean Explanation: Instructions on lid hygiene (to keep the lid margins clean and free of exudates) are given to the client. Treatment of a stye includes warm soaks of the area and incision and drainage. The client is not required to sleep with the face parallel to the floor.

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select?

Levin tube Explanation: A Levin tube is a single lumen nasogastric tube. A Salem sump tube is a double lumen nasogastric tube; a Sengstaken-Blakemore tube is a triple lumen nasogastric tube. A Miller-Abbott tube is a double lumen nasoenteric tube.

A nurse is caring for a client with a BMI of 35 kg/m2 who is wanting to lose weight. What is the initial recommendation the nurse will expect from the client's health care provider?

Lifestyle modification Explanation: All answer choices represents the various treatment for obesity; however, lifestyle modification is the initial recommendation for weight loss.

After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. What should the nurse do based on the assessment findings?

Listen longer for the sounds. Explanation: Auscultation is used to determine the character, location, and frequency of bowel sounds. The frequency and character of sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minutes. Normal sounds are heard about every 5 to 20 seconds, whereas hypoactive sounds can be one or two sounds in 2 minutes. Postoperatively, it is common for sounds to be reduced; therefore, the nurse needs to listen at least 3 to 5 minutes to verify absent or no bowel sounds.

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?

Liver Explanation: The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client?

Liver transplant Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients.

A nurse cares for a client who is post op bariatric surgery. Which position will the nurse place the client in order to best promote comfort?

Low Fowler's Explanation: Positioning the client in low Fowler's position best promotes comfort in the client who is post op bariatric surgery. In addition to decreasing incisional pain, this position also promotes gastric emptying.

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?

Low residue Explanation: Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.

Which of the following are functions of saliva? Select all that apply. Lubrication Digestion Metabolism Protection against harmful bacteria Elimination

Lubrication Digestion Protection against harmful bacteria Explanation: The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:

Make a notation on the call light system that the client cannot speak. 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.

Hearing aids help with which of the following problems?

Makes sounds louder Explanation: A hearing aid makes sounds louder, but it does not improve a patient's ability to discriminate words or understand speech. Hearing aids amplify all sounds, including background noise, which may be disturbing to the wearer. It does not improve communication skills.

A nurse is planning care for a client who will be arriving to the unit postoperatively from bariatric surgery. In an effort to decrease the risk of venous thromboembolism (VTE), which health care provider orders does the nurse anticipate?

Mechanical compression and prophylactic anticoagulation Explanation: Both mechanical compression (intermittent pneumatic compression devices) and prophylactic anticoagulation with low molecular weight heparin agents are prescribed in the client who is postoperative bariatric surgery. Early ambulation is encouraged; however, it is not the only intervention.

The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack?

Meclizine (Antivert) Explanation: Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack (NIDCD, 2010).

Rebleeding may occur from a peptic ulcer and often warrants surgical interventions. Signs of bleeding include which of the following?

Mental confusion Explanation: Signs of bleeding include tachycardia, tachypnea, hypotension, mental confusion, thirst, and oliguria.

A nurse is preparing to conduct preoperative teaching with a client. Which of the following actions should the nurse take?

Minimize distractions in the room The nurse should establish an environment that is conducive to learning, which includes minimizing distractions and noise in the room.

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?

Myopia Explanation: Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which affects both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly but near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treat inflammatory conditions of the eyes?

NSAIDs Explanation: NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

Notify the surgeon about the tube's removal. Explanation: If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the health care provider. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the health care provider who will make a determination of leaving out or inserting a new nasogastric tube.

Peptic ulcer disease occurs more frequently in people with which blood type?

O Explanation: People with blood type O are more susceptible to peptic ulcers than those with blood type A, B, or AB.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. Explanation: A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.

A nurse practitioner prescribes drug therapy for a patient with peptic ulcer disease. Choose the drug that can be used for 4 weeks and has a 90% chance of healing the ulcer.

Omeprazole Explanation: Omeprazole (Prilosec) is a proton pump inhibitor that, if used according to the health care provider's directions, will result in healing in 90% of patients. The other drugs are H2 receptor antagonists that need to be used for 6 weeks.

The nurse on a cruise ship is assessing clients for motion sickness. Which of the following is a common misconception?

Once symptoms occur, they will always be present. Explanation: When the client experiences motion sickness, the client will use that data to avoid further symptoms in the future. The client can use medication, change location or position, and recognize symptoms earlier for symptom management. The other options are correct and teachable statements.

An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?

Palpate the client's parotid glands to detect swelling and tenderness. Explanation: Older adults and debilitated clients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.

A 66-year-old African-American client has recently visited a physician to confirm a diagnosis of gastric cancer. The client has a history of tobacco use and was diagnosed 10 years ago with pernicious anemia. He and his family are shocked about the possibility of cancer because he was asymptomatic prior to recent complaints of pain and multiple gastrointestinal symptoms. On the basis of knowledge of disease progression, the nurse assumes that organs adjacent to the stomach are also affected. Which of the following organs may be affected? Choose all that apply. Pancreas Liver Lungs Duodenum Bladder

Pancreas Liver Duodenum Explanation: Most gastric cancers are adenocarcinomas; they can occur anywhere in the stomach. The tumor infiltrates the surrounding mucosa, penetrating the wall of the stomach and adjacent organs and structures. The liver, pancreas, esophagus, and duodenum are often already affected at the time of diagnosis. Metastasis through lymph to the peritoneal cavity occurs later in the disease.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis?

Pancreatic necrosis Explanation: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?

Pentagastrin Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions.

Which of the following is an enzyme secreted by the gastric mucosa?

Pepsin Explanation: Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition?

Peptic ulcers Explanation: Chronic gastritis caused by Helicobacter pylori is implicated in the development of peptic ulcers. Chronic gastritis is sometimes associated with autoimmune disease, such as pernicious anemia, but not as a cause of the anemia. Chronic gastritis is not implicated in system infections and/or colostomies.

A nurse cares for a client with obesity who reports taking "a medication of weight loss" but cannot remember the name of it. The client also reports nervousness and feeling "jittery". Which medication is the client most likely taking?

Phentermine Explanation: Phentermine is a sympathomimetic amine that stimulates central noradrenergic receptors, causing appetite suppression. Feeling jittery and nervousness is associated with this type of medication. The other answer choices represent treatment options for obesity; however, these do not cause the client's symptoms.

A nurse cares for an older adult client with obesity who also has glaucoma. Which obesity medication is contraindicated in this client?

Phentermine Explanation: Sympathomimetic amines, such as phentermine, are contraindicated in clients with glaucoma. The other answer choices represent obesity medications; however, these are not contraindicated in clients with glaucoma.

One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right?

Pigment Explanation: There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.

The nurse is preparing to administer medication to a client who has been diagnosed with glaucoma. Which information should the nurse include related to client teaching for each of the identified medications? Pilocarpine Timolol maleate Acetazolamide

Pilocarpine - "Use safety measures in dim lighting" Timolol maleate - "It can cause hypotension." Acetazolamide - "Have your electrolyte levels monitored."

Which nursing suggestion would be most helpful to the client with recurrent otitis externa?

Place ear plugs into the ears before swimming Explanation: The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, he or she advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first?

Place the client in semi-Fowler's position. The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed Explanation: The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

Which condition refers to hearing loss associated with degenerative changes?

Presbycusis Explanation: The term presbycusis refers to hearing loss associated with degenerative changes.

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior?

Prothrombin time (PT) Explanation: The client must have coagulation studies (PT, aPTT, INR, platelet count) before the procedure because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):

Protrusion of the upper stomach into the lower portion of the thorax. Explanation: It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.

A nurse on a quality management team is developing written educational materials for clients who have varying degrees of health literacy. Which of the following strategies should the nurse include to aid the clients in effective learning?

Provide instructional materials to the client that focus on desired behavior rather than a medical facts. The nurse should provide instructional materials to the client that focus on desired behavior rather than medical facts. The nurse should include the client in the teaching and provide information that will potentially change the client's behavior, rather than focusing on the behaviors that were caused by the client's lack of knowledge. This strategy will enhance the client's interest and desire to improve behaviors, which will decrease the risk of illness.

A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse's understanding of the primary reason for this finding?

Rapid gastric dumping Explanation: Rapid gastric dumping may lead to steatorrhea, excessive fat in the feces. The primary cause of this finding is rapid gastric dumping. Excessive fat intake can make the problem worse; however, this is not the primary cause of the symptoms. Steatorrhea results from increased motility, not decreased and the size of the stomach does not contribute to this finding.

When the nurse interviews a client with internal hemorrhoids, what would the nurse expect the client to report?

Rectal bleeding Explanation: Internal hemorrhoids often cause bleeding but are usually not painful. Severe pain is associated with external hemorrhoids, due to the inflammation and edema caused by thrombosis. Pus is associated with an anorectal abscess or anal fistula. While straining against hard stools due to constipation is one potential cause of hemorrhoids, there are many other causes including chronic diarrhea, pregnancy, prolonged sitting, and others.

A client with gallstones is diagnosed with acute pancreatitis and is requesting information about the physiology of the gallbladder. Which information will the nurse include about the function of this organ?

Releases bile in response to cholecystokinin Explanation: The gallbladder is a pear-shaped, hollow, saclike organ that lies in a shallow depression on the inferior surface of the liver. When food enters the duodenum, the gallbladder contracts and the sphincter of Oddi relaxes. Relaxation of this sphincter allows the bile to enter the intestine. This response is mediated by secretion of the hormone cholecystokinin (CCK) from the intestinal wall. Gallstones can block the bile duct and digestive juices to the pancreas causing acute pancreatitis. The gallbladder functions as a storage depot for bile. Bile does not digest carbohydrates in the jejunum. The liver controls the flow of trypsin to digest proteins.

A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?

Reserving a site for a peripherally inserted central catheter (PICC) Explanation: Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve a site for placement of a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect?

Right shoulder pain The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help with client comfort.

Which diagnostic test distinguishes between conductive and sensorineural hearing loss?

Rinne test Explanation: Rinne test is useful for distinguishing between conductive and sensorineural hearing loss. In the whisper test, the client with normal acuity can correctly repeat what was whispered from 1 to 2 feet away. Audiometry is used to detect hearing loss. The Weber test uses bones conduction to test lateralization of sound.

A client has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the client's care?

Risk for Aspiration Related to Inhalation of Gastric Contents Explanation: Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the client's nutritional status and does not affect cardiac output or communication.

A nurse is caring for a client who is post operative bariatric surgery. The client's pain has not been well controlled. Which nursing diagnosis is the nurse's priority?

Risk for impaired gas exchange Explanation: A postoperative bariatric client with uncontrolled pain is at great risk for pulmonary complications because the client is unable to take deep breaths. The other nursing diagnoses are appropriate for the client; however, these are not priority.

Which category of laxatives draws water into the intestines by osmosis?

Saline agents (e.g., magnesium hydroxide) Explanation: Saline agents use osmosis to stimulate peristalsis and act within 2 hours of consumption. Bulk-forming agents mix with intestinal fluids, swell, and stimulate peristalsis. Stimulants irritate the colon epithelium. Fecal softeners hydrate the stool by surfactant action on the colonic epithelium, resulting in a mixing of aqueous and fatty substances.

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear?

Scleral buckle Explanation: The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.

During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a:

Sensorineural loss. Explanation: Noise-induced hearing loss refers to hearing loss that follows a long period of exposure to loud noise. It is inherent in jobs that involve heavy machinery, noisy engines, and artillery.

What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids?

Serous otitis media Explanation: Serous otitis media, a collection of pathogen-free fluid behind the tympanic membrane, results from irritation associated with respiratory allergies and enlarged adenoids. The other options are distractors for this question. Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections.

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 amylase Explanation: 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.

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiasis Explanation: Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.

A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal?

Slows gastric emptying Explanation: Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.

Which symptom is related to vertigo?

Spinning sensation Explanation: Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them.

An older client is diagnosed with parotitis. What bacterial infection does the nurse suspect caused the client's parotitis?

Staphylococcus aureus Explanation: The elderly and debilitated clients experience decreased salivary flow from general dehydration or medications. The bacterial infection is usually caused by Staphylococcus aureus. The infecting organism travels from the mouth through the salivary gland. Pseudomonas, pneumococcus, and streptococcus are less likely to specifically affect the elderly or debilitated clients.

Which of the following occurs when there is deviation from perfect ocular alignment?

Strabismus Explanation: Strabismus is a condition in which there is deviation from perfect ocular alignment. Ptosis is a drooping eyelids. Chemosis is edema of the conjunctiva. Nystagmus is an involuntary oscillation of the eyeball.

Select the assessment finding that the nurse should immediately report, post radical neck dissection.

Stridor Explanation: Stridor is the presence of coarse, high-pitched sounds on inspiration. The nurse would auscultate frequently over the trachea. This finding must be immediately reported because it indicates airway obstruction.

A client is recently diagnosed with Crohn's disease and is beginning treatment. What first-line treatment does the nurse expect that the client will be placed on to decrease the inflammatory response?

Sulfasalazine Explanation: Considered first-line treatment for inflammatory bowel disease, 5-ASA drugs contain salicylate, which is bonded to a carrying agent that allows the drug to be absorbed in the intestine. These drugs work by decreasing the inflammatory response. Methotrexate or azathioprine are used when failure to maintain remission necessitates the use of an immune-modulating agent. Ciprofloxacin is used as an effective adjunct to treat the disease.

A client comes to the clinic complaining of a sore throat. When assessing the client, the nurse observes a reddened ulcerated lesion on the lip. The client tells the nurse that it has been there for a couple of weeks but it does not hurt. What should the nurse consult with the health care provider about testing for?

Syphilis Explanation: The primary lesion of syphilis is a chancre, which is a reddened circumscribed lesion that ulcerates and becomes crusted.

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

Take long, slow breaths Explanation: During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.

A client comes to the walk-in clinic complaining of an earache. The cause is found to be impacted cerumen. The client asks the nurse what he can do at home to soften hardened cerumen. What should the nurse recommend to a client to soften hardened cerumen?

Take nonprescription preparations. Explanation: The nurse should recommend nonprescription preparations that are available for softening hardened cerumen. Increasing the intake of red meat or beta-carotene or avoiding harsh sunlight will not soften the cerumen.

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this?

Tetany related to hypocalcemia Explanation: A client with acute pancreatitis who reports muscle cramping or pain should be suspected of having hypocalcemia and tetany of the muscles. Hypocalcemia may occur in acute pancreatitis because, when auto digestion of the pancreas occurs, calcium binds to fatty acids and calcium is decreased in the blood. This is a potentially life-threatening complication of pancreatitis and needs to be immediately addressed.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control?

The client exhibits signs of adequate GI perfusion. Explanation: Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply. The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours). The health care provider will be able to determine if there is a presence of bowel disease. The client must have bowel cleansing prior to the procedure.

The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours). Explanation: The client should be NPO for 8 hours prior to the examination. Before the introduction of the endoscope, the client is given a local anesthetic gargle or spray. Midazolam (Versed), a sedative that provides moderate sedation with loss of the gag reflex and relieves anxiety during the procedure, is administered. Temporary loss of the gag reflex is expected; after the client's gag reflex has returned, lozenges, saline gargle, and oral analgesic agents may be offered to relieve minor throat discomfort.

Which is a true statement regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobblestone appearance. Explanation: The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.

A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?

The consistency of stool and comfort when passing stool Explanation: In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination. People differ greatly in their bowel habits and normal bowel patterns range from three bowel movements per day to three bowel movements per week. It is important for the stool to be soft to pass without pain. The client may not be able to fully evacuate with a bowel movement; it may take time.

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse?

The head of the bed is elevated 20 degrees The head of the bed should be elevated at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation.

When conducting an eye exam, the nurse practitioner is aware that a diagnostic clinical manifestation of glaucoma is:

The presence of halos around lights. Explanation: Most patients are unaware that they have glaucoma until they experience visual changes and vision loss. Usually the patient notices blurred vision and the presence of "halos" around lights.

A nurse cares for a client who is post op bariatric surgery and the nurse offers the client a sugar-free beverage. What is the primary purpose of offering a sugar-free beverage?

These are less likely to cause dumping syndrome. Explanation: The primary purpose of offering a sugar-free beverage is that they are less likely to cause dumping syndrome in the client who is post op from bariatric surgery. Sugar-free beverages are less likely than sugary beverages to raise the blood sugar; however, this is not the primary purpose of offering the sugar-free beverage. Sugar-free beverages do not necessarily ease nausea or gastric distention.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following?

To detect an ulceration in the stomach An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment?

To prevent vision loss Explanation: Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason?

To reduce gastric and pancreatic secretions Explanation: Anticholinergic medications reduce gastric and pancreatic secretion.

When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase?

Triglycerides Explanation: Pancreatic lipase acts on lipids, especially triglycerides. Salivary amylase and pancreatic amylase act on starch. Pepsin and hydrochloric acid in the stomach and trypsin from the pancreas act on proteins. Insulin acts on glucose.

The nurse is conducting a gastrointestinal assessment. When the client reports the presence of mucus and pus in the stool, the nurse assesses for additional signs/symptoms of which disease/condition?

Ulcerative colitis Explanation: The presence of mucus and pus in the stool suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client?

Uncontrolled rhythmic movements of the face or limbs Explanation: Metoclopramide is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely for uncontrolled rhythmic movements of the face or limbs. Metoclopramide side effects are headache, confusion, and drowsiness. Anxiety, hyperactivity, and a dry mouth are not common side effects.

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?

Vagus Explanation: Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.

A client is diagnosed with Meniere's disease. The nurse would most likely expect the client to report which of the following?

Vertigo Explanation: Although tinnitus, nausea, vomiting and ear fullness may be noted, vertigo is usually the most troublesome and common complaint associated with Meniere's disease.

The clinical manifestations of motion sickness are caused by an overstimulation in what system?

Vestibular Explanation: Motion sickness is a disturbance of equilibrium caused by constant motion. The syndrome manifests itself in sweating, pallor, nausea, and vomiting caused by vestibular overstimulation. Motion sickness is not caused by cardiovascular, cochlear, or gastrointestinal overstimulation.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K Explanation: Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

A nurse is preparing to provide care for a client whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the client's stools will have what characteristics?

Watery with blood and mucus Explanation: The predominant symptoms of ulcerative colitis are diarrhea and abdominal pain. Stools may be bloody and contain mucus. Stools are not hard, dry, tarry, black or fatty in clients who have ulcerative colitis.

A nurse cares for clients with obesity. Which clinical measurements use quantified measurements to diagnose obesity? Select all that apply. Blood pressure Total cholesterol Weight BMI Waist circumference

Weight BMI Waist circumference

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions Explanation: The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). No clinical evidence supports the use of meperidine for pain relief in pancreatitis, and, in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

alcohol abuse and smoking. Explanation: The nurse should mention that risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren't risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

The digestion of carbohydrates is aided by

amylase. Explanation: Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration. Explanation: Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding?

clear liquids clear liquids, such as water or broth, can be given for the first oral feedings, but should be limited to only 30mL (1oz) per feeding. Water does not contain sugar, which could cause diarrhea due to hyperosmolarity.

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called:

conductive hearing loss. Explanation: Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response?

cranial nerve VIII Explanation: Nerve receptors for balance are found both in the vestibule and semicircular canals. They transmit information about motion through the vestibular nerve, which joins with the cochlear nerve to form the eighth cranial nerve (formally called the auditory or acoustic nerve).

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

drink liquids only between meals. Explanation: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. The client has the following oral medications prescribed: furosemide, digoxin, enteric coated aspirin, and vitamin E. The nurse would withhold which medication?

enteric coated aspirin Explanation: Simple compressed tablets (furosemide, digoxin) may be crushed and dissolved in water. Soft gelatin capsules filled with liquid (vitamin E) may be opened, and the contents squeezed out. Enteric coated tablets (enteric coated aspirin) are not to be crushed and a change in the form of the medications is required.

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing

facial nerve paralysis. Explanation: If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend?

foods high in fiber The result of long term low fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High fiber foods help strengthen and maintain active motility of the GI tract.

The major carbohydrate that tissue cells use as fuel is

glucose. Explanation: Glucose is the major carbohydrate that tissue cells use as fuel. Proteins are a source of energy after they are broken down into amino acids and peptides. Chyme stays in the small intestine for 3 to 6 hours, allowing for continued breakdown and absorption of nutrients. Ingested fats become monoglycerides and fatty acids by the process of emulsification.

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation?

lack of free water intake Explanation: A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:

light flashes and floaters in front of the eye. Explanation: The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question?

metoclopramide Explanation: The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

The Zollinger-Ellison syndrome (ZES) consists of severe peptic ulcers, extreme gastric hyperacidity, and gastrin-secreting benign or malignant tumors of the pancreas. The nurse recognizes that an agent that is used to decrease bleeding and decrease gastric acid secretions is

octreotide (Sandostatin) Explanation: For patients with ZES, hypersecretion of acid may be controlled with high doses of H2 receptor antagonists. These clients may require twice the normal dose, and dosages usually need to be increased with prolonged use. Octreotide (Sandostatin), a medication that suppresses gastrin levels, also may be prescribed.

An older adult client reports pain in the ears and an unusual sense of fullness. The client also indicates not hearing as well as in the past. On inspection, the nurse notes that there is an accumulation of earwax in the client's ears. The client is suffering from:

otalgia. Explanation: Otalgia is ear pain or an earache. Otalgia has several causes, one of which is accumulated earwax.

A client with multiple sclerosis is being seen by a neuro-ophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:

perimetry test Explanation: A visual field test or perimetry test measures peripheral vision and detects gaps in the visual field

A client has noticed needing to hold printed material at arms length to make the print readable. What is the term used to describe this visual condition?

presbyopia Explanation: Presbyopia is associated with aging and results in difficulty with near vision. People with presbyopia hold reading material or handwork at a distance to see it more clearly. My

A nurse notices that a client's left upper eyelid is drooping.

ptosis Explanation: Ptosis is drooping or falling of the upper or lower eyelid. Ptolemy is not a medical condition. Proptosis is the extended or protruded upper eyelid that delays closing or remains partially open. Nystagmus is uncontrolled oscillating movement of the eyeball.

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for

recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black.

The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer?

red plaque on undersurface of tongue Explanation: Red or white plaque located on the undersurface of the tongue can be indicative of oral cancer. A thin, white coating on the dorsum of the tongue and large vallate papillae that form a V on the distal portion of the tongue are normal findings.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred?

rigid abdomen abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotensive results.

The most significant complication related to continuous tube feedings is

the increased potential for aspiration. Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Which enzyme aids in the digestion of protein?

trypsin Explanation: Trypsin, amylase, and lipase are digestive enzymes secreted by the pancreas. Trypsin aids in digesting protein; amylase aids in digesting starch; and lipase aids in digesting fats. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein. Amylase is an enzyme that aids in the digestion of starch. Steapsin digests fats.

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications?

vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.

The nurse recognizes which change of the GI system is an age-related change?

weakened gag reflex Explanation: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.

The nurse recognizes which change of the gastrointestinal system is an age-related change?

weakened gag reflex Explanation: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

yellow sclerae. Explanation: 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.

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment?

Ask the client to empty the bladder. Explanation: The physical examination of the gastrointestinal system includes assessment of the mouth, abdomen, and rectum. It requires good light, full exposure of the abdomen, warm hands with short nails, and a relaxed client with an empty bladder. A full bladder will interfere with inspection and may elicit discomfort with palpation and percussion, thereby altering results.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?

Assess lung sounds bilaterally. Explanation: All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. Malignant hyperthermia Atelectasis Pneumonia Hemorrhage Chronic gastritis

Atelectasis Pneumonia Hemorrhage

A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? Limit fluid intake not related to meals Chew on mint leaves to relieve indigestion Avoid eating within 3 hr of bedtime Season foods with black pepper

Avoid eating within 3 hr of bedtime The nurse should instruct the client to eat small, frequent meals but to avoid eating with 3 hr of bedtime.

The nurse reviews dietary guidelines with a client who had a gastric banding. Which teaching points are included? Select all that apply. Eat six meals a day. Avoid fruit drinks and soda. Limit meal size to 450 to 500 mL. Do not eat and drink at the same time. Drink plenty of water, from 90 minutes after each meal to 15 minutes before each meal.

Avoid fruit drinks and soda. Do not eat and drink at the same time. Drink plenty of water, from 90 minutes after each meal to 15 minutes before each meal. Explanation: Total meal size should be restricted to less than 8 oz or 240 mL. Three meals a day are recommended.

When assisting with preparing a client scheduled for a barium swallow, what nursing instruction would be appropriate to include?

Avoid smoking for at least a day before the procedure. Explanation: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.

A young adult client is prescribed misoprostol to prevent gastric ulcers caused by frequent use of nonsteroidal anti-inflammatory agents for an autoimmune disorder. For which reason will the nurse question giving the client a dose of this medication?

Awaiting the results of a pregnancy test Explanation: Misoprostol is a synthetic prostaglandin that protects the gastric mucosa from agents that cause ulcers, and also increases mucus production and bicarbonate levels. It is a pregnancy category X medication and should not be taken by a pregnant client as it can soften the cervix and result in miscarriage or premature labor. This medication does not cause constipation. Sucralfate needs to be taken without food. Misoprostol can cause diarrhea and cramping; however, this is not the reason to question giving the client a dose of the medication.

Which drug is considered a stimulant laxative?

Bisacodyl Explanation: Bisacodyl is a stimulant laxative. Magnesium hydroxide is a saline agent. Mineral oil is a lubricant. Psyllium hydrophilic mucilloid is a bulk-forming agent.

The physician suggests that a client use meclizine as treatment for his motion sickness. The nurse explains the rationale for this drug based on an understanding of which of the following as the drug's action?

Blocks conduction of the vestibular pathways Explanation: Meclizine blocks the conduction of the vestibular pathway in the inner ear to provide some relief of nausea and vomiting. Anticholinergic agents, such as scopolamine, antagonize the histamine response. Meclizine does not depress the central nervous system. Diuretics help to lower the pressure of the endolymphatic system in Meniere's disease.

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect?

Boardlike abdomen The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?

Borborygmus Explanation: Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrhea.

Which term refers to intestinal rumbling?

Borborygmus Explanation: Borborygmus is the intestinal rumbling caused by gas moving through the intestines that accompanies diarrhea. Tenesmus refers to ineffectual straining upon evacuation of stool. Azotorrhea refers to excess nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter), resulting in abscess formation.

The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the client then experiences diarrhea, the nurse documents the presence of which condition?

Borborygmus Explanation: Borborygmus is the intestinal rumbling caused by the movement of gas through the intestines that accompanies diarrhea. Tenesmus refers to ineffectual straining at stool. Azotorrhea refers to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.

A nurse researcher is reviewing data obtained from a developing nation on nutrition and metabolism issues facing that country. What is the nurse's understanding of the "double-burden" many developing nations now face?

Both undernutrition and obesity Explanation: The WHO mentions that many developing nations now face a double-burden of both undernutrition and obesity. Both of these issues occur simultaneously and create a public health burden to developing nations.

The nurse is caring for a client with increased fluid accumulation in the eye. When assessing the client, which structure within the eye is noted to drain fluid from the anterior chamber?

Canal of Schlemm Explanation: The canal of Schlemm drains the anterior chamber of the eye. By draining the fluid, it decreases the fluid amount and pressure in the eye. The other options have no draining ability.

A nurse cares for a client with obesity who takes anticonvulsant medication for the treatment of epilepsy. Which anticonvulsant medications may be contributing to the client's obesity? Select all that apply. Zonisamide Topiramate Lamotrigine Carbamazepine Gabapentin

Carbamazepine Gabapentin Explanation: Carbamazepine (Tegretol) and gabapentin (Neurontin) are anticonvulsant medications that may cause weight gain. The other medications listed are anticonvulsant medications; however, these are associated with weight loss, not gain.

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired?

Carbohydrate digestion Explanation: Amylase is a pancreatic enzyme involved in the breakdown and digestion of carbohydrates. Trypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

Which foods should be avoided following acute gallbladder inflammation?

Cheese Explanation: The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

A client was hit in the eye with a stick. The nurse notes edema to the conjunctiva. What documentation by the nurse describes the assessment findings?

Chemosis Explanation: Chemosis is a common manifestation of pinkeye. Papilledema refers to swelling of the optic disk due to increased intracranial pressure. Proptosis is the downward displacement of the eyeball. Strabismus is a condition in which there is a deviation from perfect ocular alignment.

Which is a correct rationale for encouraging a client with otitis externa to eat soft foods?

Chewing may cause discomfort. Explanation: The nurse encourages a client with otitis externa to eat soft foods or consume nourishing liquids because chewing may cause discomfort. Chewing will not react with the prescribed medications or cause complications such as otitis media and excessive drainage.

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid Nonfat milk Chocolate Apples Oatmeal

Chocolate The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.

A client with calculi in the gallbladder is said to have

Cholelithiasis Explanation: 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.

Which medication classification increases aqueous fluid outflow in the client with glaucoma?

Cholinergics Explanation: Cholinergics increase aqueous fluid outflow by contracting the ciliary muscle, causing miosis, and opening the trabecular meshwork. Beta-blockers decrease aqueous humor production. Alpha-adrenergic agonists decrease aqueous humor production. Carbonic anhydrase inhibitors decrease aqueous humor production.

A client is prescribed a histamine (H2)-receptor antagonist. The nurse understands that this might include which medication(s)? Select all that apply. Cimetidine Lansoprazole Nizatidine Famotidine Esomeprazole

Cimetidine Nizatidine Famotidine Explanation: H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton-pump inhibitors.

The nurse is irrigating a client's colostomy when the client begins to report cramping. What is the appropriate action by the nurse?

Clamp the tubing and allow client to rest. Explanation: The nurse should clamp the tubing and allow the client to rest when the client begins to report cramping during colostomy irrigation. Once the cramping has stopped, the nurse can resume the irrigation.

The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?

Clamp the tubing and give the patient a rest period. Explanation: When irrigating a colostomy, the nurse should allow tepid fluid to enter the colon slowly. If cramping occurs, the nurse should clamp off the tubing and allow the patient to rest before progressing. Water should flow in over a 5- to 10-minute period.

A client has a tumor of the head of the pancreas. What clinical manifestations will the nurse assess? Select all that apply. Clay-colored stools Dark urine Jaundice Weight gain Persistent hiccups

Clay-colored stools Dark urine Jaundice Explanation: Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected. Persistent hiccups are seen with stomach and bowel diseases.

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Select all that apply. Clay-colored stools Dark urine Jaundice Pruritus Weight gain

Clay-colored stools Dark urine Jaundice Pruritus Explanation: The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools Explanation: The client with gallstones has clay-colored stools and excruciating upper right quadrant 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.

Which nursing goal is a priority when caring for a client newly diagnosed with vertigo?

Client will remain safe while ambulating in the home. Explanation: Safety is always a concern when a client is experiencing vertigo. The goal of the nurse's instruction and care is for the client to remain safe. Maintaining a therapeutic medication schedule and caretaker and establishing strategies to reduce symptoms are important but not of highest priority.

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium?

Colonoscopy Explanation: A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?

Colonoscopy Explanation: Diverticulosis is typically diagnosed by colonoscopy, which permits visualization of the extent of diverticular disease and biopsy of tissue to rule out other diseases. In the past, barium enema was the preferred diagnostic test, but it is now used less frequently than colonoscopy. CT with contrast agent is the diagnostic test of choice if the suspected diagnosis is diverticulitis; it can also reveal abscesses.

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consults with the physician about decreasing the feeding to half-strength Explanation: The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consults with the physician about decreasing the feeding to half-strength Explanation: The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution.

Which of the following is the main refracting surface of the eye?

Cornea Explanation: The cornea is a transparent, avascular, domelike structure that covers the iris, pupil, and anterior chamber. It is the most anterior portion of the eyeball and is the main refracting surface of the eye. The iris is the colored part of the eye. The pupil is a space that dilates and constricts in response to light. Normal pupils are round and constrict symmetrically when a bright light shines on them. The conjunctiva provides a barrier to the external environment and nourishes the eye.

A client sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this client?

Curling's ulcer Explanation: Curling's ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum. Peptic, esophageal, and Meckel's ulcers are not related to burn injuries.

A client with obesity reports taking orlistat in order to aid in weight loss. Which medication order for the client will the nurse question?

Cyclosporine Explanation: Clients taking orlistat (Xenical) should not take cyclosporine. The other answer choices do not represent interactions if taking concurrently with orlistat.

A nurse is providing discharge instruction for a client who is postoperative bariatric surgery. What statement will the nurse include when providing teaching aimed at decreasing the risk of gastric ulcers?

"Avoid taking non-steroidal anti-inflammatory drugs." Explanation: The only statement that aids in avoiding gastric ulcers is the statement instructing the client to avoid taking non-steroidal anti-inflammatory (NSAID) drugs. Sitting in a semi-recumbent of low Fowler's position aids in digestion but does not aid in the prevention of gastric ulcers. Propping the head of the bed would be beneficial for a client report GERD or acid reflux. antacid drugs do not increase the risk of gastric ulcers.

A nurse is caring for a client with constipation whose primary provider has recommended senna for the management of this condition. The nurse should provide which of the following education points?

"Avoid taking the drug on a long-term basis." Explanation: Laxatives should not be taken on an ongoing basis in order to reduce the risk of dependence. Fluid should be increased, not limited, and there is no need to take each dose with a multivitamin. Senna does not need to be taken on an empty stomach.

A client is prescribed tetracycline to treat peptic ulcer disease. Which instruction would the nurse give the client?

"Be sure to wear sunscreen while taking this medicine." Explanation: Tetracycline may cause a photosensitivity reaction in clients. The nurse should caution the client to use sunscreen when taking this drug. Dairy products can reduce the effectiveness of tetracycline, so the nurse should not advise him or her to take the medication with milk. GI upset is possible with tetracycline administration. Administration of tetracycline does not necessitate driving restrictions.

A nurse cares for an obese client taking phentermine for weight loss. What client teaching will the nurse include when discussing precautions about the medication?

"Do not drink alcohol while taking this medication." Explanation: The nurse should tell the client to avoid drinking alcohol while taking this medication. The other answer choices are not as important as avoiding the drug/alcohol interaction associated with this medication.

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." Explanation: The nurse should instruct the client to avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes) for 30 days after a stapedectomy. Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. The client must avoid shampooing and swimming to keep the dressing and the ear dry.

A nurse is obtaining the health history of a client who has diabetes mellitus. Which of the following questions should the nurse ask to evaluate their understanding of the disease?

"How has your illness altered your typical daily activities?" This question can help the nurse determine areas where the client has insufficient knowledge or is misinformed. Once it is determined how the illness affects the client's usual activities, the nurse can develop instructions for teaching the client how to self-manage the illness and provide information about available community resources.

The nurse is assessing a client admited with suspected pancreatitis. Which question will the nurse prioritize when assessing this client?

"How much alcohol do you consume in a day?" Explanation: Chronic pancreatitis is an inflammatory disorder characterized by progressive destruction of the pancreas. Alcohol consumption in Western societies is the major cause of chronic pancreatitis. Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of chronic pancreatitis. The incidence of pancreatitis is 50 times greater in people with alcoholism than in those who do not abuse alcohol. The type of food (like fried or heavily processed foods) rather than the number of meals eaten each day may contribute to pancreatitis and subsequent flare-ups of the condition. The prescibed use of acetaminophen is not a typical risk factor in pancreatitis and is rare with cases of overdose. The amount and/or lack of exercise is not directly linked to pancreatitis. Risk factors do include obesity.

The spouse of a client recovering from a partial gastrectomy for cancer is concerned about the client's nutrition once discharged home. Which response will the nurse make?

"I can ask a dietitian to talk with you about foods and meal preparation." Explanation: A part of self-care after surgery for gastric cancer is education about diet and nutrition. Since the spouse is concerned about meal preparation at home, a dietitian can be consulted to discuss the client's needs with the spouse. The foods that the spouse normally prepares may not be appropriate for the client recovering from gastric surgery. Diet and nutrition are major concerns to promote healing. The client may not have an appetite and may not desire any particular type of food.

A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?

"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." Explanation: The client stating that he ate roast beef on rye bread indicates the need for a dietary consult because rye bread contains gluten, which must be eliminated from the client's diet. The client stating that he's followed the ordered medication regimen and diet doesn't suggest that the client needs a dietary consult; a treatment regimen consisting of medications to improve symptoms and dietary modification is necessary to treat celiac disease. The client stating that he hasn't traveled outside of the country doesn't suggest that dietary concerns exist. The client saying that he can't have oatmeal shows an understanding of the dietary restrictions necessary with celiac disease.

The nurse identifies the nursing diagnosis of deficient knowledge related to a new hearing aid for a client. After teaching a client about caring for his new hearing aid, the nurse determines that the outcome has been achieved when the client states which of the following?

"I need to keep my ear canal clean and dry." Explanation: The client demonstrates understanding of the care of a hearing aid when stating the need to keep the ear canal clean and dry. The ear mold is the only part of the hearing aid that can be washed frequently, that is daily with soap and water. It should be allowed to dry completely before it is snapped into the receiver or inserted into the ear.

The nurse provides client education to a client about to undergo hydrogen breath testing. The nurse evaluates that the client understands the test when the client makes which statement?

"I should avoid antibiotics for 1 month before the test." Explanation: The nurse evaluates that the client understands the education when the client states antibiotics should be avoided one month before the test. In addition, the client should avoid loperamide, sucralfate, and omeprazole for 1 week prior to the test, and cimetidine, famotidine, and nizatidine for 24 hours before the test. During the test, the client swallows a capsule of carbon-labeled urea and a breath sample is obtained 10 to 20 minutes later. The hydrogen breath test detects the presence of <italic>Helicobacter pylori, the bacteria that causes peptic ulcer disease.

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

"I should become involved in a weight loss program." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

The nurse instructs a client on care at home after a laparoscopic cholecystectomy. Which client statement indicates that teaching has been effective?

"I should wash the site with mild soap and water." Explanation: After a laparoscopic cholecystectomy, the client should be instructed about pain management, activity and exercise, wound care, nutrition, and follow-up care. The client should be directed to wash the puncture site with mild soap and water when caring for the wound. When resuming activity, the client should be instructed to drive after 3 or 4 days, take a shower or bath after 1 or 2 days, and begin light exercise such as walking immediately.

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching? "I will continue my low-dose aspirin therapy regimen" "I will refrain from eating raw fruits and vegetables" "I will avoid steak and other red meats" "I will continue taking my Coumadin as prescribed"

"I will continue taking my Coumadin as prescribed" The client should discontinue anticoagulants for one week prior to this testing. This statement requires clarification.

A nurse is providing teaching to a client who has oral candidiasis and a new prescription for nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching?

"I will store the medication at room temperature" Nystatin oral suspension should be stored at room temperature.

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?

"I'll eat frequent, small, bland meals that are high in fiber." Explanation: In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To minimize intra-abdominal pressure and decrease gastric reflux, the client should eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver). Eating three large meals daily would increase intra-abdominal pressure, possibly worsening the hiatal hernia. The client should avoid spicy foods, alcohol, and tobacco because they increase gastric acidity and promote gastric reflux. To minimize intra-abdominal pressure, the client shouldn't recline after meals, lift heavy objects, or bend.

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?

"I'll have to wear an external collection pouch for the rest of my life." Explanation: The client requires additional teaching if he states that he'll have to wear an external collection pouch for the rest of his life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection. Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily.

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?

"I'll have to wear an external collection pouch for the rest of my life." Explanation: The client requires additional teaching if he states that he'll have to wear an external collection pouch for the rest of his life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection. Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily.

A nurse cares for a client with interstitial pancreatitis. What client teaching will the nurse include when planning care for the client?

"Inflammation is confined to only the pancreas." Explanation: There are two forms of pancreatitis-inflammatory and necrotizing. Interstitial pancreatitis is characterized by diffuse enlargement of the pancreas due to inflammatory edema confined only to the pancreas itself; normal function returns after about 6 months. Necrotizing pancreatitis is life-threatening and tissue necrosis occurs within the pancreas as well as the surrounding glands.

A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "It is a hereditary disease." "Is it possible that you are overusing aspirin." "It is probably your nerves."

"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." Explanation: Acute gastritis is often caused by dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate.

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:

"It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?

"It is a vent that prevents backflow of the secretions." Explanation: The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.

A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include? "Elevate the head of your bed by 18 inches" (should be 6-12 inches) "Avoid snacking between meals" "Limit foods that are high in fiber" "Lie on your right side when sleeping"

"Lie on your right side when sleeping" The nurse should instruct the client to lie on the right side when sleeping to prevent nighttime reflux.

A client is diagnosed with a corneal abrasion and the nurse has administered proparacaine hydrochloride per orders to assess visual acuity. The client requests a prescription for this medication because it completely took away the pain. What is the best response by the nurse?

"Prescriptions of this medication are generally not given because it can cause corneal problems." Explanation: Proparacaine hydrochloride can cause corneal softening and other complications if overused. Clients with corneal abrasions or other painful eye disorders have a tendency to overuse the medication, thus leading to the complications. It would not be appropriate to give the bottle with written instructions, and it is not a standard prescription for eye disorders because of the complications from overuse. Telling the client that you will let the doctor know does not provide the education needed about this medication.

A client with obesity will undergo intragastric balloon therapy for weight loss. What teaching will the nurse include when educating the client about this procedure? Select all that apply. "The balloon via a minimally-invasive surgery." "The balloon will remain in place for 3 to 6 months." "This procedure has shown greater weight loss results when compared to bariatric surgery." "Nausea and vomiting are the most commonly reported side effects." "This procedure works by causing malabsorption of fat."

"The balloon will remain in place for 3 to 6 months." "Nausea and vomiting are the most commonly reported side effects."

A client with a peptic ulcer is diagnosed with Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole, omeprazole, and clarithromycin. Which statement by the client indicates the best understanding of the medication regimen?

"The medications will kill the bacteria and stop the acid production." Explanation: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton-pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton-pump inhibitor (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton-pump inhibitor and bismuth salts (Pepto-Bismol). Research is being conducted to develop a vaccine against H. pylori.

A client being treated for a peptic ulcer seeks medical attention for vomiting blood. Which statement indicates to the nurse the reason for the client developing hematemesis?

"The pain stopped so I stopped taking the medications." Explanation: The client should be instructed to adhere to and complete the medication regimen to ensure complete healing of the peptic ulcer. Because most clients become symptom free within a week, it should be stressed to the client the importance of following the prescribed regimen so that the healing process can continue uninterrupted and the return of symptoms can be prevented. Since the client stopped taking the medication, the ulcer was not healed and became worse. The statements about soda, being nauseated, and eating only one meal would not explain the reason for the client's new onset of hematemesis during treatment for a peptic ulcer.

The nurse is supervising a family member who instilling ear drops into the client's ear. Which of the following statements, made by the family member, would require further nursing instruction?

"These drops are cold from being on the window sill." Explanation: When the family member states that the drops are cold, the nurse would encourage the family member to place the bottle in a warm bath or warm the bottle in their hands. Cold or hot liquids, instilled in the ear, may cause dizziness and potential for injury.

A client with obesity is prescribed lorcaserin for weight loss. The client reports dry mouth. What is the nurse's best response?

"This is an expected finding with this medication." Explanation: Lorcaserin (Belviq), a selective serotonergic 5-HT2C receptor agonist, causes dry mouth. This is an expected and normal finding. Increasing fluid intake does not make this symptom go away. The other answer choices are incorrect.

A client discharged after a laparoscopic cholecystectomy calls the surgeon's office reporting severe right shoulder pain 24 hours after surgery. Which statement is the correct information for the nurse to provide to this client?

"This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort." Explanation: If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

A client who is obese and the nurse have established a goal for the client to achieve a weight loss of 1 pound each week. One month later, the nurse evaluates that the client has lost 2 pounds. The nurse first states

"You have succeeded in making positive progress." Explanation: In the evaluation stage of the nursing process, the nurse validates even small increments toward goal achievement, as reflected in statement b. This is important for enhancement of client self-esteem and reinforcing client behavior. Change is a slow process, and success may be defined as making some progress. The nurse and client will then need to re-evaluate the goal, as in statement d, and either continue with the current goal, change the goal, or discontinue the goal. Statements a and c are negative criticisms and would diminish client self-esteem.

A nurse is caring for a client who has a new diagnosis of Lyme disease. The client states, "I've decided on a therapy plan, but I wish I knew how this happened to me. I always take good care of myself." Which of the following responses should the nurse make?

"You say you've made a decision about treatment, although you seem to be focusing on how it could've been prevented." In this response, the nurse is using the therapeutic communication technique of confrontation. When the nurse uses confrontation in a therapeutic way, it helps the client to realize inconsistencies in their behavior, recognize growth, and make important decisions.

A client's vision is assessed at 20/200. The client asks what that means. Which is the most appropriate response by the nurse?

"You see an object from 20 feet away that a person with normal vision sees from 200 feet away." Explanation: The fraction 20/20 is considered the standard of normal vision. Most people, positioned 20 feet from an eye chart, can see the letters designated as 20/20 from a distance of 20 feet.

A nurse cares for a female client of childbearing age who will undergo bariatric surgery. When teaching the client about precautions after surgery, which teaching will the nurse include that is specific to this population?

"You should avoid pregnancy for at least 18 months after surgery." Explanation: When teaching a female of childbearing age regarding precautions after bariatric surgery, the nurse should instruct the client to avoid pregnancy for at least 18 months after surgery. The ability to conceive after weight loss surgery may improve more often than worsen. Contraceptives are no less effective after surgery than before.

A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate?

"You'll need to use the drops for the rest of your life to control the glaucoma." Explanation: The client is demonstrating a lack of understanding about the condition and its treatment. The nurse needs to provide additional information to the client that the condition can be controlled but not cured. The statement about lifelong therapy would be most appropriate. Eye medications would most likely be needed for the long term, not just a few months. Surgery may be used in conjunction with medication therapy; however, neither method cures the condition. The goal of therapy is to reduce the intraocular pressure to prevent optic nerve damage. In some clients, medication may be all that is needed. In other cases, additional or combination treatment with surgery or laser procedures may be necessary.

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280 Explanation: The output measured includes the two 20 mL irrigations. To determine the actual output, the nurse would subtract the amount of irrigation used (in this case 40 mL total) from the total output (in this case 320 mL) and arrive at an output of 280 mL.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood glucose level does the nurse recognize as inadequate to sustain normal brain function?

30 mg/dL Explanation: Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulin-like material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

When discussing lifestyle modifications with a client who has obesity, what caloric deficit should the nurse recommend in order for the client to safely lose weight?

500-1,000 calories Explanation: A client with obesity should be counseled to plan a caloric deficit of between 500 and 1000 calories daily from baseline, in order to achieve a 5% to 10% reduction in weight within about 6 months.

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?

6 Explanation: Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?

6 to 12 Explanation: Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

Which symptoms may a client with Ménière disease report before an attack?

A full feeling in the ear Explanation: Clients with Ménière disease experience symptoms of headache and a full feeling in the ear before an attack. Nystagmus is an episodic symptom that occurs during an attack, and, at times, the client is symptom free. Ménière disease does not cause low blood pressure or photosensitivity.

A patient comes to the clinic with a suspected eye infection. The nurse recognizes that the patient most likely has conjunctivitis, as evidenced by what symptom?

A mucopurulent ocular discharge Explanation: Bacterial conjunctivitis manifests with an acute onset of redness, burning, and discharge. There is papillary formation, conjunctival irritation, and injection in the fornices. The exudates are variable but are usually present on waking in the morning. The eyes may be difficult to open because of adhesions caused by the exudate. Purulent discharge occurs in severe acute bacterial infections, whereas mucopurulent discharge appears in mild cases.

The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing Explanation: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client. The eardrum appears pinkish-orange from structural changes in the middle ear. The client often describes a history of having had a recent upper respiratory infection in case of otitis media, not otosclerosis.

The client has been diagnosed with objective vertigo. Which symptom would the nurse relate to the tentative diagnosis?

A sensation of things moving Explanation: Objective vertigo includes the sensation that the environment is moving or a sense that things are moving around oneself. The symptoms do not include a headache, pain in the outer ear, and difficulty hearing.

When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the initial appropriate action by the nurse?

A) Assess the client's abdomen and vital signs Signs and symptoms of perforation includes sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm. The nurse should assess the vital signs and abdomen prior to notifying the physician. Irrigation of the NG tube should not be performed because the additional fluid may be spilled into the peritoneal cavity, and the client should be placed in a position of comfort, usually on the side with the head slightly elevated.

The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?

Abdominal distention Explanation: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.

A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems?

Acute gastritis Explanation: A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. A client with a duodenal ulcer will present with heartburn, nausea, excessive gas and vomiting. A client with gastric cancer will have persistent symptoms of nausea and vomiting, not sudden symptoms. A client with a gastric ulcer will have bloating, nausea, and vomiting, but not necessarily hiccups.

The nurse provides care to a menopausal client, who states, "I read a news article that says I am at risk for coronary vascular disease due to inflammation." Which method should the nurse suggest to the client to aid in the prevention of inflammation that can lead to atherosclerosis?

Addressing obesity Explanation: The 2019 ACC/AHA Guideline on the Primary Prevention of Coronary Vascular Disease (CVD) indicates a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests that decreasing obesity and body fat stores via exercise, dietary modification, or developing drugs that target proinflammatory proteins may reduce risk factors for heart disease. The risk for CVD accelerates for clients after menopause due to withdrawal of endogenous estradiol levels, which can worsen many traditional CVD risk factors, including body fat distribution. Avoiding the use of caffeine, using a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to atherosclerosis.

The postoperative nurse is attending beginning-of-shift report and learns that a client who is recovering from bariatric surgery has been experiencing bile reflux. What is the nurse's most appropriate action?

Administer proton pump inhibitors as prescribed Explanation: Bile reflux may be managed with proton pump inhibitors, not calcium supplements or pancreatic enzymes. This complication does not necessitate a cholecystectomy and changes in food intake do not resolve it.

A nurse is teaching a client and the client's family about chronic pancreatitis. Which are the major causes of chronic pancreatitis?

Alcohol consumption and smoking Explanation: Alcohol consumption in Western societies is a major factor in the development of chronic pancreatitis, as is smoking. Because heavy drinkers usually smoke, it is difficult to separate the effects of the alcohol abuse and smoking. Malnutrition is a major cause of chronic pancreatitis worldwide, but alcohol consumption is more commonly the cause in Western societies. Caffeine consumption is not related to acute pancreatitis. Acute hepatitis does not usually lead to chronic pancreatitis unless complications develop.

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition?

Alcohol use Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?

Amsler grid Explanation: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.

Which of the following digestive enzymes aids in the digesting of starch?

Amylase Explanation: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme.

Which feature should a nurse observe during an ophthalmic assessment?

Appearance of the external eye Explanation: During an ophthalmic assessment, the nurse should examine the appearance of the external eye and the pupil responses in the client. A qualified examiner determines internal eye function, visual acuity, and intraocular pressure.

A nurse caring for a client who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What is an expected, normal amount of drainage?

Approximately 80 to 120 mL Explanation: Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.

While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?

Approximately 80 to 120 mL Explanation: Wound drainage tubes are usually inserted during surgery to prevent the collection of fluid subcutaneously. The drainage tubes are connected to a portable suction device (e.g., Jackson-Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours

What concepts does the nurse understand about gerontologic considerations related to acute pancreatitis? Select all that apply. As the client ages, there is an increased risk for the development of acute pancreatitis. As the client ages, there is an increased mortality rate for acute pancreatitis. As the client ages, there is an increased risk for the development of multiple organ dysfunction syndrome. As the client ages, the pattern of complications related to acute pancreatitis changes. As the client ages, the size of the pancreas decreases, increasing the risk of developing acute pancreatitis.

As the client ages, there is an increased mortality rate for acute pancreatitis. As the client ages, there is an increased risk for the development of multiple organ dysfunction syndrome. As the client ages, the pattern of complications related to acute pancreatitis changes. Explanation: Gerontologic considerations must be remembered when caring for older adult clients with acute pancreatitis. Clients of all ages may develop acute pancreatitis; however, mortality rate for acute pancreatitis increases as the client ages. Additionally, as the client ages, the pattern of complications related to acute pancreatitis changes and the risk of developing multiple organ dysfunction syndrome (MODS) increases with age. The size of the pancreas does not decrease as the client ages.

The nurse is providing discharge education to an adult client who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the client is able to self-administer these medications safely and effectively?

Ask the client to demonstrate the instillation of her medications. Explanation: The client or the caregiver at home should be asked to demonstrate actual eye drop administration. This method of assessment is more accurate than asking the client to describe the process or determining earlier inabilities to self-administer medications. The client's functional status will not necessarily determine the ability to administer medication safely.

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?

Assess the graft for color and temperature. Explanation: Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.

A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber. Explanation: The nurse should assist the client to increase the dietary fiber in food because it helps reduce constipation. Providing an adequate quantity of food is necessary in maintaining sufficient nutrition and in sustaining normal body weight. Obtaining medical, allergy, and food history would provide valuable information, however, it would not help reduce constipation.

The nurse is providing care for a client who had a biliopancreatic diversion with duodenal switch 2 days ago. How should the nurse best address the client's risk for postoperative venous thromboembolism?

Assist the client with ambulating as early and often as possible Explanation: Early ambulation is a key intervention in the prevention of VTE. Coumadin is not used for postoperative VTE prophylaxis. Breathing exercises prevent respiratory complications, not VTE. Repositioning preserves the client's skin integrity.

The nurse and a colleague are performing the Epley maneuver with a client who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action?

Assisting the client into a sitting position Explanation: The Epley maneuver is performed by placing the client in a sitting position, turning the head to a 45-degree angle on the affected side, and then quickly moving the client to the supine position. Saline is not instilled into the ears and there is no need to assess hearing before the test.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?

Assisting the client to turn, cough, and deep breathe every 2 hours Explanation: Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

The nurse is teaching a group of clients with obesity about the risks of disease associated with obesity. Which respiratory conditions or diseases will the nurse include in the teaching, which are associated with obesity? Select all that apply. Asthma Infection Obstructive sleep apnea Central sleep apnea Emphysema

Asthma Infection Obstructive sleep apnea Explanation: Respiratory conditions associated with obesity include asthma, obstructive sleep apnea, and respiratory infections. Central sleep apnea and emphysema are not obesity-related conditions.

An older adult client is admitted to an acute care facility for treatment of an acute flare-up of a chronic gastrointestinal condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the gastrointestinal tract. Which age-related change increases the risk of anemia?

Atrophy of the gastric mucosa Explanation: Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages. A decrease in hydrochloric acid increases, not decreases, intestinal flora; as a result, the client is at increased risk for infection, not anemia. A reduction, not increase, in bile secretion may lead to malabsorption of fats and fat-soluble vitamins. Dulling of nerve impulses associated with aging increases the risk of constipation, not anemia.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

Auscultate lung sounds every 4 hours. Explanation: Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?

BUN and creatinine Explanation: Angiography is done using fluorescein or indocyanine green as contrast agents. Fluorescein angiography is used to evaluate clinically significant macular edema, document macular capillary nonperfusion, and identify retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein. Prior to the angiography, the patient's blood urea nitrogen (BUN) and creatinine should be checked to ensure that the kidneys will excrete the contrast agent (Fischbach & Dunning, 2011).

A client you are caring for has a hearing loss. The client tells you he is self-conscious about his hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his self-esteem?

Be forthright and inform others about the hearing deficit. Explanation: The nurse should encourage clients with a hearing loss to be forthright and inform others about their hearing deficit. Clients should be advised not to hide the fact that they do not understand what has been said and should be encouraged to maintain friendships because a physical impairment is unlikely to affect genuine friendships.

An ophthalmologist diagnoses a patient with myopia. The nurse explains that this type of impaired vision is a refractive error characterized by:

Blurred distance vision. Explanation: People who have myopia are said to be nearsighted. They have deeper eyeballs; thus, the distant visual image focuses in front of, or short of, the retina. Myopic people experience blurred distance vision.

The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?

Boerhaave syndrome Explanation: Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

Which of the following implanted hearing devices transmits sound through the skull to the inner ear?

Bone conduction devices Explanation: Bone conduction devices, which transmit sound through the skull to the inner ear, are used in patients with a conductive hearing loss if a hearing aid is contraindicated. A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. A conventional hearing aid is external only.

A patient with IBD would be encouraged to increase fluids, use vitamins and iron supplements, and follow a diet designed to reduce inflammation. Select the meal choice that would be recommended for a low-residue diet.

Broiled chicken with low-fiber pasta Explanation: A low-residue, high-protein, and high-calorie diet is recommended to reduce the size and number of stools. Foods to avoid include yogurt, fruit, salami, and peanut butter.

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client?

Brush and floss daily. Explanation: The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.

A nurse inspects the Stensen duct of the parotid gland to determine inflammation and possible obstruction. What area in the oral cavity would the nurse examine?

Buccal mucosa next to the upper molars Explanation: The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.

Which of the following brain structures is responsible for equilibrium?

Cerebellum Explanation: Body balance is maintained by the cooperation of the muscles and joints of the body (proprioceptive system), the eyes (visual system), and the labyrinth (vestibular system). These areas send information about equilibrium, or balance, to the brain (cerebellar system) for coordination and perception in the cerebral cortex. The brainstem, thalamus, and hypothalamus do not function in equilibrium.

The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

Change in bowel habits Explanation: The chief characteristic of cancer of the colon is a change in bowel habits, such as alternating constipation and diarrhea. Excess gas, daily bowel movements, and abdominal cramping when having a bowel movement are not indicators of colon cancer.

A nurse is planning care for a client who will undergo bariatric surgery in a week. What goals are acceptable during this point in the client's care? Select all that apply. Client will become knowledgeable about the procedure. Client will understand preoperative and postoperative dietary restrictions. Client will have decreased anxiety about the procedure. Client will understand how to maintain normal bowel function. Client will become knowledgeable about vitamin requirements.

Client will become knowledgeable about the procedure. Client will understand preoperative and postoperative dietary restrictions. Client will have decreased anxiety about the procedure. Explanation: Prior to surgery, the client should be knowledgeable about the procedure and understand the pre and postoperative dietary requirements. Additionally, the client should also have decreased anxiety about the procedure. Understanding maintenance of normal bowel function and vitamin requirements occur postoperatively.

The nurse is caring for a client recovering from acute pancreatitis. Which menu item should the nurse remove from the client's breakfast tray?

Coffee Explanation: Post-acute management of the client with acute pancreatitis includes the introduction of solid food. Oral feedings that are low in fat and protein are gradually initiated. Caffeine is eliminated from the diet and therefore coffee, which contains caffeine, should be removed from the client's breakfast tray. Even decaffeinated coffee has a small amount of caffeine but could serve as a compromise for chronic coffee drinkers. The other food items are appropriate for the client.

The nurse is working with a client who has difficulty controlling blood sugar. The client is classified as overweight. The client does not adhere to a low-calorie diet and forgets to take medications and check blood glucose level. The client's glycohemoglobin is 8.5%. When establishing a goal for the client, what action will the take first?

Collaborates with the client to establish an agreed-upon goal Explanation: When establishing a goal, the nurse should collaborate with the client. The nurse does not dictate to the client what the goal will be. Goals must be consistent with the abilities and motivation of the client. The long-term and short-term goals may not be realistic for this client.

Which statement provides accurate information regarding cancer of the colon and rectum?

Colorectal cancer is the third most common site of cancer in the United States. Explanation: Cancer of the colon and rectum is the third most common site of new cancer cases in the United States. Colon cancer affects more than twice as many people as does rectal cancer (94,700 for colon, 34,700 for rectum). The incidence increases with age (the incidence is highest in people older than 85). Colon cancer occurrence is higher in people with a family history of colon cancer.

The nurse plans care for a client with obesity. What does the nurse recognize is the primary pathophysiological reason clients with obesity are at greater risk for developing thromboembolism?

Compromised peripheral blood flow Explanation: A client with obesity is at increased risk for developing thromboembolism due to compromised blood flow and resulting venous stasis. Although the client with obesity is at risk for high cholesterol levels, increased fat in the blood does not directly impact the risk for developing thromboembolism. Increased blood viscosity and impaired clotting do not typically occur in obesity and are not the reason a client with obesity would be at greater risk for developing thromboembolism.

An initial, convenient assessment of an older adult client's complaint of hearing loss would be inspection, using an otoscope, for the presence of impacted cerumen. Which of the following is a primary cause of an external ear disorder in the elderly?

Conduction problem Explanation: Conductive hearing loss usually results from an external ear disorder, such as impacted cerumen, or a middle ear disorder, such as otitis media or otosclerosis. In such instances, the efficient transmission of sound by air to the inner ear is interrupted.

The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate?

Conductive Explanation: Conductive hearing loss occurs from an obstruction in the outer or middle ear such as from cerumen. Mixed hearing loss is a combination of conductive and sensorineural problems. Central hearing loss involves injury or damage to the nerves or the nuclei of the central nervous system. Sensorineural involves damage to the inner ear.

Which statement is consistent with acute otitis media?

Conductive hearing loss may occur. Explanation: Approximately three in four children experience an ear infection by the time they are 3 years of age. The infection usually lasts less than 6 weeks. Conductive hearing loss may occur due to a purulent exudate. Bacteria and viruses, not fungi, are the most common causes of otitis media.

During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as:

Conductive. Explanation: A defect in the tympanic membrane or interruption of the ossicular chain disrupts normal air conduction, which results in a conductive hearing loss.

The nurse is providing preoperative care for a client with gastric cancer who is having a resection. What is the nursing management priority for this client?

Correcting nutritional deficits Explanation: Clients with gastric cancer commonly have nutritional deficits and may have cachexia. Therefore, correcting nutritional deficits is a top priority. Discharge planning before surgery is important, but correcting the nutritional deficits is a higher priority. Radiation therapy hasn't been proven effective for gastric cancer, and teaching about it preoperatively wouldn't be appropriate. Preventing DVT isn't a high priority before surgery, but it assumes greater importance after surgery.

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube?

Cranberry juice Explanation: To unclog a feeding tube, air insufflation, digestive enzymes mixed with warm water, or a commercial enzyme product could be used. Cola and cranberry juice are no longer advocated for use in clearing a clogged tube.

A client is having a diagnostic workup for reports of frequent diarrhea, right lower abdominal pain, and weight loss. The nurse is reviewing the results of the barium study and notes the presence of "string sign." What does the nurse understand that this is significant of?

Crohn's disease Explanation: The most conclusive diagnostic aid for Crohn's disease has classically been a barium study of the upper GI tract that shows a "string sign" on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.

Which ulcer is associated with extensive burn injury?

Curling ulcer Explanation: Curling ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

What type of medication would the nurse use in combination with mydriatics to dilate the patient's pupil?

Cycloplegics Explanation: Mydriasis, or pupil dilation, is the main objective of the administration of mydriatics and cycloplegics (Table 63-3). These two types of medications function differently and are used in combination to achieve the maximal dilation that is needed during surgery and fundus examinations to give the ophthalmologist a better view of the internal eye structures.

An older adult client seeks help for chronic constipation. What factor related to aging can cause constipation in elderly clients?

Decreased abdominal strength Explanation: Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly. A decrease in hydrochloric acid causes a decrease in absorption of iron and vitamin B12, whereas an increase in intestinal bacteria actually causes diarrhea.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?

Decreases in the physiologic function of major organs Explanation: Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

The nurse is preparing a client for a test that involves inserting a thick barium paste into the rectum with radiographs taken as the client expels the barium. What test will the nurse prepare the client for?

Defecography Explanation: In defecography, a thick barium paste is inserted into the rectum. Radiographs are taken as the client expels the barium to determine whether there are any anatomic abnormalities or problems with the muscles surrounding the anal sphincter. A KUB will not determine this. Colonic transit studies are used to determine how long it takes for food to travel through the intestines. Abdominal radiography will show the structure but does not determine the muscle ability surrounding the anal sphincter.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volume Explanation: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?

Dumping syndrome Explanation: Osmolality is an important consideration for clients receiving tube feedings through the duodenum or jejunum because feeding formulas with a high osmolality may lead to undesirable effects. When a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The client may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, which indicates dumping syndrome. The client's symptoms are not caused by a diverticulosis, paralytic ileus, or a small bowel obstruction.

A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event?

Dumping syndrome Explanation: Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that occur in up to 76% of patients who have had bariatric surgery. Early symptoms include a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. These symptoms resolve once the intestine has been evacuated (i.e., with defecation).

The nursing student approaches his instructor to discuss the plan of care for his client diagnosed with peptic ulcer disease. The student asks what is the most common site for peptic ulcer formation? The instructor would state which one of the following?

Duodenum Explanation: Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin.

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes mellitus. Which of the following explains the cause of this secondary diabetes?

Dysfunction of the pancreatic islet cells Explanation: Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver.

The nurse is caring for a patient who has malabsorption syndrome with an undetermined cause. What procedure will the nurse assist with that is the best diagnostic test for this illness?

Endoscopy with mucosal biopsy Explanation: Endoscopy with biopsy of the mucosa is the best diagnostic tool for malabsorption syndrome.

As a nurse completes the admission assessment of a client admitted for gastric bypass surgery, the client states, "Finally! I'll be thin and able to eat without much concern." How should the nurse intervene?

Evaluate the client's understanding of the procedure. Explanation: The nurse should evaluate the client's understanding of the procedure. The client may not understand that surgery alone isn't a cure for obesity; lifestyle modifications and counseling are also necessary. Based on the client's comment, the client isn't fully informed; therefore, signing an informed consent form without further teaching would be inappropriate. Rejoicing with the client is inappropriate. Asking the client about plans for after surgery redirects the conversation away from the client's misinterpretation of the procedure.

A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir?

Every 4 to 6 hours Explanation: The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. This prevents the accumulating effluent from spilling or causing infection.

A client has been prescribed eye drops for the treatment of glaucoma. At the yearly follow-up appointment, the client tells the nurse that she has stopped using the medication because her vision did not improve. Which action by the nurse is appropriate?

Explain the therapeutic effect and expected outcome of the medication. Explanation: The nurse needs to explain the therapeutic effect and expected outcome of the medication. The medication is not a cure for glaucoma, but can slow the progression. The client will not see improvements in vision with the use of the medication but should experience little to no deterioration of vision. The doctor may choose to switch the medication, but not because the vision is not improving; it would be based on not obtaining the set intraocular pressure. Administering the medication immediately or referring the client to the emergency department is not appropriate because this is not an emergent

A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?

External auditory canal erythema Explanation: An erythematous external auditory canal would be considered an abnormal finding. The tympanic membrane is normally pearly gray and translucent. The umbo, which is located in the center of the eardrum, extends from the superior manubrium.

The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?

Extraocular muscle function Explanation: The nurse is testing the client's extraocular eye muscle function by having the client follow an object through the six cardinal directions of gaze (up, down, right, left, and both diagonals). Pupillary reaction is tested using a penlight. The nurse observes the position of the eyelids for drooping. The nurse asks a client to stare at an object and then each eye is covered and then uncovered quickly while the examiner looks for any shifts in the eye and oscillations in the eyeball.

A client with progressive hearing loss is diagnosed with a malignant tumor of the right external ear. For which additional alteration in physical status will the nurse assess the client?

Facial nerve paralysis Explanation: Malignant tumors may occur in the external ear. Most common are basal cell carcinomas on the pinna and squamous cell carcinomas in the ear canal. If untreated, squamous cell carcinoma may spread through the temporal bone, causing facial nerve paralysis and hearing loss. Since the client is already experiencing a change in hearing, the facial nerve needs to be assessed. The client does not need to be assessed for a frontal headache, cervical node edema, or parotid gland hypertrophy.

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing which effect?

Facial nerve paralysis Explanation: If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.

A client who is postoperative bariatric surgery is diagnosed with bile reflux. Which conditions are associated with bile reflux? Select all that apply. Gastritis Esophagitis Pharyngitis Laryngitis Tonsillitis

Gastritis Esophagitis Explanation: Bile reflux may cause gastritis or esophagitis. Pharyngitis, laryngitis, and tonsillitis are associated with pulmonary conditions and not associated with bile reflux.

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition?

Gastroesophageal reflux disease Explanation: Metoclopramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.

Which precaution should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance?

Have the client wait for help before moving Explanation: The nurse should have the client wait to move until help arrives. Safety measures such as assisted ambulation are implemented to prevent falls and injury. The client should restrict movement. The client should keep his or her eyes open and focus on one spot to reduce vertigo.

A client who is postoperative open RYGB bariatric surgery is scheduled for discharge and will have a Jackson-Pratt drain to care for while at home. Which teaching will the nurse include specific to this? Select all that apply. How to change the drain How to empty the drain Recording drainage amount When to contact the health care provider How to measure the drainage amount

How to empty the drain Recording drainage amount When to contact the health care provider How to measure the drainage amount Explanation: A client who is discharged with a Jackson-Pratt drain must be taught on methods to measure, record, and empty the drain. Additionally, the nurse should instruct the client on when to contact the health care provider. The client will not change the drain, this is reserved for the health care provider only.

A nurse is performing health education with a client who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis?

Imbalanced Nutrition: Less Than Body Requirements Explanation: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a person's nutritional status. Dental caries do not typically affect the client's tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.

A client with Crohn's disease is losing weight. For which reason will the nurse anticipate the client being prescribed parenteral nutrition?

Impaired ability to absorb food Explanation: A client with Crohn's disease will have an impaired ability to ingest or absorb food orally or enterally. Clients with severe burns, malnutrition, short-bowel syndrome, AIDS, sepsis, and cancer would need parenteral nutrition because of insufficient oral intake. Unwillingness to ingest nutrients orally would cause a client with a major psychiatric illness to need parenteral nutrition. Prolonged surgical nutritional needs such as what occurs after extensive bowel surgery or acute pancreatitis would necessitate the need for parenteral nutrition.

The nurse is admitting a client with traumatic injuries who also has class III obesity. When planning this client's care, the nurse should address the client's heightened risk of what nursing diagnoses related to obesity? Select all that apply. Impaired skin integrity Impaired gas exchange Unilateral neglect Deficient fluid volume Bowel incontinence

Impaired skin integrity Impaired gas exchange Explanation: Obesity creates risks for ineffective respiration and consequent impaired gas exchange due to changes in the structure and function of the respiratory system. As well, obesity is associated with risks to skin integrity due to the possibility of pressure injuries. There is no accompanying risk of bowel incontinence or fluid volume deficit that is accounted for by obesity. If neglect exists, it is likely to be bilateral, not unilateral.

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

Inner ear Explanation: A client with vertigo experiences problems with the inner ear, which is responsible for maintaining equilibrium. The external ear collects sound; the middle ear conducts sound. The tympanic membrane (eardrum) vibrates in response to sound stimulation.

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is

Inserted into the lungs Explanation: The alert client may cough constantly and have difficulty with respirations when the nasogastric tube enters the lungs. The client may cough but will not have difficulty with respirations with the nasogastric tube coiling in the mouth or irritating the epiglottis. Usually if the nasogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea.

A client diagnosed with a peptic ulcer says, "Now I have something else I have to worry about." Which actions will the nurse take to help reduce the client's anxiety? Select all that apply. Interact with the client in a relaxed manner. Help identify the client's current stressors. Discuss potential coping techniques with the client. Offer information about relaxation methods. Inform the client the medication will solve the problem.

Interact with the client in a relaxed manner. Help identify the client's current stressors. Discuss potential coping techniques with the client. Offer information about relaxation methods. Explanation: A client with a peptic ulcer may have a problem with anxiety. To help reduce the client's anxiety, the nurse should interact with the client in a relaxed manner and help the client identify stressors. The nurse can also discuss potential coping techniques and offer information about relaxation methods. Stating that medication will solve the problem may not be sufficient if stress and anxiety are contributors to the development of the ulcer.

A nurse geneticist is researching the gut microbiome and its relationship to disease. What is true regarding the microbiome?

It has over 100 times more genes than the human genome. Explanation: The collective genome of the microbiota, or the gut microbiome, has more than 100 times more genes than in the human genome. Its function and relationship to disease has long been studied.

The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program?

It is the third most common cancer in the United States. Explanation: Colorectal cancer is the third most common type of cancer in the United States. The lifetime risk of developing colorectal cancer is 1 in 20. The incidence increases with age (the incidence is highest in people older than 85). Colorectal cancer occurrence is higher in people with a family history of colon cancer.

The instructor is teaching a group of students about irritable bowel syndrome (IBS) and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an antidiarrheal agent commonly administered for IBS?

Loperamide Explanation: Loperamide is an opiate-related antidiarrheal agent. Lubiprostone is used to treat constipation; it activates chloride channels in the gastrointestinal tract to increase gastrointestinal transit. Dicyclomine, a smooth muscle antispasmodic agent, is used to treat pain accompanying IBS. Peppermint oil may also be taken to ease discomfort.

The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?

Maintaining skin integrity Explanation: Fecal incontinence can disrupt perineal skin integrity. Maintaining skin integrity is a priority, especially in the debilitated or older adult patient.

Swallowing is regulated by which area of the central nervous system (CNS)?

Medulla oblongata Explanation: Swallowing begins as a voluntary act that is regulated by the swallowing center in the medulla oblongata of the CNS. The act of swallowing requires the innervations of five cranial nerves (CNs), especially CN V, VII, IX, X, and XII. Swallowing is not regulated by the pons, cerebellum, or hypothalamus.

Which of the following is considered a bulk-forming laxative?

Metamucil Explanation: Metamucil is a bulk-forming laxative. Milk of Magnesia is classified as a saline agent. Mineral oil is a lubricant. Dulcolax is a stimulant.

A client with obesity is diagnosed with type 2 diabetes. In order to promote weight loss in the client and aid in glucose management, which medication will the nurse anticipate the health care provider ordering?

Metformin Explanation: Metformin (Glucophage) is a diabetes medication that also promotes weight loss. The other medications are diabetes medications; however, these promote weight gain, not weight loss.

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct?

Monitoring the feeding closely. Explanation: High residual volumes (>200 mL) should alert the nurse to monitor the client more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the client's risk for aspiration.

A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow?

Monitoring the stool passage and its color. Explanation: Monitoring stool passage and its color will ensure that the client remains barium free following a barium swallow test. The white or clay color of the stool would indicate barium retention. The stool should be placed in a special preservative if the client undergoes a stool analysis. Observing the color and volume of urine will not ensure that the client is barium free because barium is not eliminated through urine but through stool.

Celiac disease (celiac sprue) is an example of which category of malabsorption?

Mucosal disorders causing generalized malabsorption Explanation: Celiac disease (celiac sprue, gluten-sensitive enteropathy) results from a toxic response to the gliadin component of gluten by the surface epithelium of the intestine; eventually, the mucosal villi of the small intestine become denuded and cannot function. Crohn's disease (regional enteritis) and radiation enteritis are other examples of mucosal disorders. Examples of infectious diseases causing generalized malabsorption include small-bowel bacterial overgrowth, tropical sprue, and Whipple disease. Examples of luminal problems causing malabsorption include bile acid deficiency, Zollinger-Ellison syndrome, and pancreatic insufficiency. Postoperative gastric or intestinal resection and cancer can result in development of a lymphatic malabsorption syndrome, in which there is interference with the transport of the fat by-products of digestion into the systemic circulation.

A client diagnosed with colon cancer presents with the characteristic symptoms of a left-sided lesion. Which symptoms are indicative of this disorder? Select all that apply. Black, tarry stools Narrowing stools Constipation Dull abdominal pain Abdominal distention

Narrowing stools Constipation Abdominal distention Explanation: Melena and dull abdominal pain are associated with right-sided lesions. The other symptoms are found with left-sided lesions.

The nurse in the ED admits a client with suspected gastric outlet obstruction. The client's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order?

Nasogastric tube insertion Explanation: The nurse anticipates an order for nasogastric tube insertion to decompress the stomach. Pelvic x-ray, oral contrast, and stool specimens are not indicated at this time.

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance?

No land line; cell phone available and taken by family member during working hours Explanation: A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal.

Which of the following is an involuntary rhythmic movement of the eyes that is also associated with vestibular dysfunction?

Nystagmus Explanation: Nystagmus is an involuntary rhythmic movement of the eyes; pathologically it is an ocular disorder but is also associated with vestibular dysfunction. Nystagmus can be horizontal, vertical, or rotary, and can be caused by a disorder in the central or peripheral nervous system. Vertigo is defined as the misperception or illusion of motion of the person or their surroundings. Tinnitus is ringing in the ears. Presbycusis is a progressive hearing loss.

The nurse is preparing a teaching tool on pancreatic cancer. Which risk factor(s) will the nurse include in this tool? Select all that apply. Obesity Diabetes Aspirin use Alcohol intake Cigarette smoking

Obesity Diabetes Alcohol intake Cigarette smoking Explanation: The incidence of pancreatic cancer increases with age, peaking in the seventh and eighth decades for both men and women. Risk factors for the development of pancreatic cancer include obesity and diabetes. The risk of pancreatic cancer is greater in those with a history of increased pack years of cigarette smoking and in those with high alcohol intake. Aspirin use is not an identified risk factor for the development of pancreatic cancer.

Which medication classification represents a proton (gastric acid) pump inhibitor?

Omeprazole Explanation: Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.

Which of the following medications is classified as a proton pump inhibitor (PPI)?

Omeprazole Explanation: Omeprazole is classified as a PPI. Nizatidine, cimetidine, and famotidine are classified as H2 receptor antagonists.

The nurse recognizes the following as marker(s) of medication effectiveness in glaucoma control except:

Opacity of the lens Explanation: The main markers of the efficacy of the medication in glaucoma control are lowering of the intraocular pressure to the target pressure, stable appearance of the optic nerve head, and the visual field. Opacity of the lens relates to cataract formation.

A client with obesity reports pain in the joints. Which musculoskeletal condition related to obesity does the nurse suspect the client has?

Osteoarthritis Explanation: Osteoarthritis is an obesity-related musculoskeletal condition. Rheumatoid arthritis, inflammatory arthritis, and necrotizing arthritis are not obesity-related conditions.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?

Pancreatitis Explanation: 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.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

Pancreatitis Explanation: Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis?

Pancreatitis can elevate the diaphragm and alter the breathing pattern. Explanation: Aggressive pulmonary care is required for clients with acute pancreatitis. Pancreatitis can elevate the diaphragm and alter the breathing pattern of clients. Pancreatitis can cause retention of pulmonary secretions but does not thicken the secretions. Acute pancreatitis does not alter the hemoglobin.

Which term refers to swelling of the optic disc due to increased intracranial pressure?

Papilledema Explanation: Papilledema is swelling of the optic disc due to increased intracranial pressure. Chemosis is edema of the conjunctiva. Ptosis is a drooping eyelid. Photophobia is ocular pain on exposure to light.

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?

Potassium-rich foods Explanation: The nurse should encourage the client with diarrhea to consume potassium-rich foods. Excessive diarrhea causes severe loss of potassium. The nurse should also instruct the client to avoid high-fiber or fatty foods because these foods stimulate gastrointestinal motility. The intake of protein foods may or may not be appropriate depending on the client's status.

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis?

Providing intensive insulin therapy Explanation: Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

A client who is recovering from bariatric surgery has not had a bowel movement for 48 hours and bowel sounds are absent on auscultation. The nurse has informed the on-call health care provider who has prescribed insertion of a nasogastric tube to low suction. What is the nurse's best action?

Question the order due to the client's recent bariatric surgery Explanation: It is contraindicated to insert a nasogastric (NG) tube in patients that have had bariatric surgery, even if they have a gastric outlet obstruction. The nurse should question the order for this reason, not because decreased motility is expected.

A client with a new diagnosis of gallstones declines surgical intervention and requests information on midigating stratergies. The nurse anticipates teaching to focus on which client behaviors and monitoring strategies?

Recommend a low fiber diet, monitor for fevers and increased abdominal girth. Explanation: The patient with gallbladder disease resulting from gallstones may develop two types of symptoms: those with disease to the gallbladder itself and those due to obstruction of the bile passages. The symptoms may be acute or chronic. Epigastric distress such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen may occur. Those at high risk may be encouraged to maintain an optimal body weight and consider reducing modifiable risk factors by avoiding consumption of sugar and sweet foods and maitaining a low fiber diet. If the gallstone obstructs the cystic duct the gallbladder becomes distended inflamed and eventually infected which results in acute cholecystitis. The patient develops a fever and may have a palpable abdominal mass. The pain of a acute cystitis may be so severe that analgesic medications are required but should not be given prophylactically which could mask a worsening condition. Jaundice occurs in a few patients with gallbladder disease usually with obstruction of the common bile duct which is frequently accompanied by pruritus (itching) of the skin. Lithotripsy is the use of shock waves to disintegrate gallstones and is a surgical procedure.

A 68-year-old client reports a change in vision when driving during the night. Which strategies would the nurse recommend to mitigate this problem?

Recommend contrast sensitivity testing measures to determine visual function. Explanation: With aging, structural and functional changes occur in the eye. Clients having visual changes while driving should have a contrast sensitivity testing done. Contrast sensitivity testing measures visual acuity in different degrees of light and dark, which determines visual function. Glare testing is also used to determine visual function. Those affected by loss of contrast sensitivity and glare have difficulty functioning in low light, or driving at night or in foggy conditions. With the results from testing, appropriate strategies can be recommended. Presbyopia, the loss of accommodative power in the lens, interferes with the ability to adequately focus (difficulty seeing small print) and is the factor responsible for most older adults requiring some form of corrective lenses. Presbyopia interferes with vision during the day and night. An eye shield is proposed for clients' postoperative management after cataract surgery. Wearing yellow tinted, not darkly tinted, glasses may help cut night glare during driving.

Which of the following is an accurate statement regarding refractive surgery?

Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. Explanation: Refractive surgery is an elective procedure and is considered a cosmetic procedure (to achieve clear vision without the aid of prosthetic devices). It is performed to reshape the cornea for the purpose of correction of all refractive errors. Refractive surgery will not alter the normal aging process of the eye. Patients with conditions that are likely to adversely affect corneal wound healing (corticosteroid use, immunosuppression, elevated intraocular pressure) are not good candidates for the procedure. The corneal structure must be normal and the refractive error stable.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing. Explanation: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged?

Removing the cerumen by means of a cotton tip applicator Explanation: The nurse is an important resource person to consult when a client has an issue with the ear structure or hearing. The nurse is correct to discourage placing anything down the ear canal that could push the cerumen deeper toward or puncture the tympanic membrane. The other options are appropriate to soften and lubricate the cerumen or to irrigate the cerumen from the ear.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk?

Reposition the client every 2 hours. Explanation: Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?

Retinal Angiography Explanation: The nurse is most correct to instruct the client that his skin and urine may turn yellow following a retinal angiography. Sodium fluorescein is a water-soluble dye that is injected into a vein. The dye then travels to the retinal arteries and capillaries, where pictures are obtained of the vascular supply. The other options do not include a dye injection.

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location?

Right lower quadrant Explanation: The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis?

Self-digestion of the pancreas by its own proteolytic enzymes Explanation: Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Of clients with acute pancreatitis, 80% had undiagnosed chronic pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?

Serum antibodies for H. pylori Explanation: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

Six small meals daily with 120 mL fluid between meals Explanation: After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.

A client has undergone a mastoidectomy. The nurse teaches the client about possible complications, instructing the client to notify the physician immediately if which of the following occur?

Slurred speech Explanation: After a mastoidectomy, the client needs to notify the physician immediately of any evidence of facial nerve weakness, such as drooping of the mouth on the operative side, slurred speech, decreased sensation, and difficulty swallowing. Aural fullness is to be expected. For 2 to 3 weeks after surgery, the client may experience sharp, shooting pains intermittently as the eustachian tube opens and allows air to enter the middle ear. A constant, throbbing pain with fever should be reported. Some serosanguinous drainage from the external auditory canal is normal after surgery.

A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose?

Stimulate GI peristalsis Explanation: Early oral hydration stimulates GI peristalsis. The nurse would not give a client oral hydration to assess for intact swallowing as this may lead to aspiration. There is no reason to assume a client would have gastric perforation and this would not be appropriate. Digestive hormones are stimulated once peristalsis begins; however, this is not the primary purpose of early oral hydration.

The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply. Stoma is pink and shiny Stoma is edematous and bleeding Formed stool in collection pouch Continuous liquid flows from the stoma Slight skin excoriation around the stoma

Stoma is pink and shiny Continuous liquid flows from the stoma Explanation: An ileostomy should be pink and shiny. The client with an ileostomy cannot establish regular bowel habits because the contents of the ileum are fluid and are discharged continuously. The stoma should not be edematous and bleeding. Formed stool in the collection pouch is a characteristic of a colostomy. Slight skin excoriation around the stoma indicates an infection or reaction to the collection appliance.

A client with peptic ulcer disease wants to know nonpharmacologic ways to prevent recurrence. Which of the following measures would the nurse recommend? Select all that apply. Substituting decaffeinated products for all forms of coffee Following a regular schedule for rest, relaxation, and meals Eating whenever hungry Avoidance of alcohol Smoking cessation

Substituting decaffeinated products for all forms of coffee Following a regular schedule for rest, relaxation, and meals Avoidance of alcohol Smoking cessation The likelihood of recurrence is reduced if the client avoids smoking, coffee (including decaffeinated coffee) and other caffeinated beverages, and alcohol. It is important to counsel the client to eat meals at regular times and in a relaxed setting and to avoid overeating.

Which of the following are methods of removing foreign bodies from the ear? Select all that apply. Suction Stapedotomy Irrigation Stapedectomy Instrumentation

Suction Irrigation Instrumentation Explanation: The three standard methods for removing foreign bodies are the same as those for removing cerumen: irrigation, suction, and instrumentation. A stapedectomy involves removing the stapes superstructure and part of the footplate and inserting a tissue graft and a suitable prosthesis for treatment of otosclerosis.

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position?

Supine with knees flexed Explanation: When examining the abdomen, the client lies supine with knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.

A client is newly diagnosed with stomach cancer. The nurse will plan to provide the client education on which treatment?

Surgery Explanation: Surgery is more hazardous for the older adult, and the risk increases proportionately with increasing age. Nonetheless, gastric cancer should be treated with surgery in older patients. Other treatments such as radiation and chemotherapy will be decided after surgery. Intermittent monitoring is not a treatment option for gastric cancer in the older adult

A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client?

Take the medication 2 hours before or after other medications Explanation: Sucralfate should be taken at least 2 hours before or after other medications. It does not decrease potassium levels and laboratory follow up is unnecessary. Sucralfate does not cause sedation.

When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply. Telephone access Family support Motivation for learning Health status Marital status

Telephone access Family support Motivation for learning Health status Explanation: Ideal candidates for home parenteral nutrition are patients who have a reasonable life expectancy after return home, have a limited number of illnesses other than the one that has resulted in the need for parenteral nutrition, and are highly motivated and fairly self-sufficient. Additional areas to consider include the client's ability to learn, availability of family interest and support, adequate finances, and the physical plan of the home including access to water, electricity, refrigeration, and telephone. The client's marital status is not important.

Prior to an eye exam for possible macular degeneration, the nurse completes a history of symptoms. The nurse is aware that a diagnostic sign of age-related dry macular degeneration is:

The appearance of tiny, yellow spots in the field of vision. Explanation: Drusen are tiny yellow spots that patients who have dry AMD report.

What would the nurse recognize as preventing a client from being able to take a fecal occult blood test (FOBT)?

The client has hemorrhoidal bleeding Explanation: FOBT should not be performed when there is hemorrhoidal bleeding. In the past, clients were taught to avoid aspirin, red meats, nonsteroidal anti-inflammatory agents, and horseradish for 72 hours prior to the examination. However, these restrictions are no longer advised as the actual effects on testing have not been established.

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?

The client is free from esophagitis and achalasia. Explanation: Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.

A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the client?

The client should discuss this new remedy with her ophthalmologist promptly. Explanation: Clients should discuss any new treatments with an ophthalmologist; this should precede the client's own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not possible.

The nurse is preparing a teaching tool about delayed release proton pump inhibitors used to treat duodenal ulcer disease caused by H. pylori. Which statement will the nurse include that would apply to most types of proton pump inhibitor prescribed to treat this condition?

The medication is to be swallowed whole and taken before meals Explanation: There are several proton pump inhibitors used to treat duodenal ulcers caused by H. pylori. For most of these medications, they are a delayed-release capsule that is to be swallowed whole and taken before meals. Pantoprazole may cause diarrhea and hyperglycemia. Rabeprazole is the only proton pump inhibitor that interferes with the metabolism of digoxin, iron, and warfarin. Rabeprazole may cause abdominal pain. Pantoprazole may cause abnormal liver function tests.

The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred?

The nurse has inadvertently inserted the tube into the trachea. Explanation: To ensure patient safety, it is essential to confirm that the tube has been placed correctly. The tube tip may be in the esophagus, stomach, or small intestine, or inadvertently inserted in the lungs, most commonly in the right main bronchus. Inappropriate placement may occur in patients with decreased levels of consciousness, confused mental states, poor or absent cough and gag reflexes, or agitation during insertion.

The nurse observes that a client's medical report indicates that the client has Cushing syndrome. During inspection, the nurse notes that the client's BMI is 31, waist circumference is 40 inches, and localized fat pads exist around the neck and upper part of the back. Which of the following must the nurse keep in mind while planning the client's care?

The nurse recognizes that the client's obesity may be specifically related to the endocrine disorder. The nurse performs a thorough nutritional assessment. Explanation: Certain signs and symptoms that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity, are easy to note because they are specific; these symptoms should be studied further. Food records, 24-hour diet recall, and dietary education directed at weight loss do not account for the client's medical condition as a factor in the client's weight or nutritional status, although each method helps estimate whether food intake is adequate and appropriate.

A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign?

The presence of halos around lights Explanation: Colored halos around lights is a classic symptom of acute-closure glaucoma.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?

The ultrasonography should be scheduled before the GI procedure. Explanation: Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

Which statement describes benign paroxysmal positional vertigo (BPPV)?

The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired. Explanation: BPPV is a brief period of incapacitating vertigo that occurs when the position of the client's head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however, generally, hearing impairment does not occur. The onset of BPPV is sudden and followed by a predisposition to positional vertigo, usually for hours to weeks but occasionally months or years. BPPV is thought to be caused by the disruption of debris within the semicircular canal. This debris forms from small crystals of calcium carbonate from the inner ear structure, the utricle. BPPV is frequently stimulated by head trauma, infection, or other events.

A client reports taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative?

They can be habit forming and will require increasing doses to be effective. Explanation: The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.

A nurse examines the socioeconomic impact of obesity among Americans. Which statements does the nurse understand is true? Select all that apply.

Those with less education are impacted at a greater prevalence of disease. Those with less income are impacted at a greater prevalence of disease. Explanation: The socioeconomic disparities of obesity among Americans is great. In general, those who are less educated and earn less income are more likely to have obesity. Home ownership does not decrease the prevalence of obesity.

What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss Explanation: It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity.

The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?

To relax colonic musculature and reduce spasm. Explanation: Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for?

Ultrasonography Explanation: Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation.

When discussing diseases of the middle ear, the nursing instructor distinguishes the different types of otitis media. What generally causes purulent otitis media?

Upper respiratory infections Explanation: Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections. It is not caused from the bronchial tree, the outer ear or irritation associated with respiratory allergies, and enlarged adenoids.

The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:

Usual pattern of elimination Explanation: Constipation has many possible causes and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?

Usual pattern of elimination Explanation: Constipation has many possible reasons and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?

Vasomotor symptoms associated with dumping syndrome Explanation: Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down. Dehiscence of the surgical wound is characterized by pain and a pulling or popping feeling at the surgical site. Peritonitis presents with a rigid, board-like abdomen, tenderness, and fever. The client's signs and symptoms aren't a normal reaction to surgery.

The nurse is talking with a patient diagnosed with Ménière's disease about the patient's symptoms. What symptom does the patient inform the nurse is the most troublesome?

Vertigo Explanation: Vertigo is the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them. Vertigo is usually the most troublesome complaint related to Ménière's disease.

Which manifestation is most problematic for the client diagnosed with Ménière disease?

Vertigo Explanation: Vertigo is usually the most troublesome complaint related to Ménière disease. Other clinical manifestations may include tinnitus, diaphoresis, and hearing loss.

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating Explanation: Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.

A nurse is preparing a presentation for a local community about hearing loss and prevention. Which of the following would the nurse integrate into the presentation as the most effective preventive measure?

Wearing ear protection when exposed to noise Explanation: Noise is a serious and very common factor associated with hearing loss. Hearing loss from noise is permanent, because noise destroys the hair cells in the organ of Corti. Therefore, wearing ear protection when exposed to noise is the most effective preventive measure available. Although appropriate ear hygiene and prompt treatment for infections are important, protecting the ears from noise is the priority. Audiometric testing is the single most important diagnostic instrument for detecting hearing loss; however, routine testing each year is not a current recommendation.

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray?

Wheat toast Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the client's tray.

A client with vertigo is scheduled to have an electronystagmography in 2 weeks. What should the nurse instruct the client to do prior to the test? Select all that apply. Withhold caffeine and alcohol 48 hours before the test. Drink a liter of fluid to help with the dye absorption Do not eat or drink anything 12 hours before testing. Withhold blood pressure medication 24 hours before the test. Withhold antivertigo agents for 5 days before the test.

Withhold caffeine and alcohol 48 hours before the test. Withhold antivertigo agents for 5 days before the test. Explanation: Electronystagmography is the measurement and graphic recording of the changes in electrical potentials created by eye movements during spontaneous, positional, or calorically evoked nystagmus. Antivertigo agents are withheld for 5 days before the test. Any vestibular suppressants, such as caffeine and alcohol, are withheld for 48 hours before testing. Clients undergoing an electronystagmography need to refer to the healthcare provider's instructions about stopping blood pressure medication. There is no special holding of food or fluids prior the study. The study does not use a dye.

A longitudinal tear or ulceration in the lining of the anal canal is termed a(n):

anal fissure. Explanation: Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A?

children The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact.

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure?

clear liquids day before Explanation: The nurse should place the client on clear liquids the evening before the procedure, a low-residue diet 1 to 2 days before the test, and NPO at midnight in preparation for the barium enema.

A client is color blind. The nurse understands that this client has a problem with:

cones. Explanation: Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?

duodenum Explanation: The duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be infertility diarrhea dyspnea dysphagia

dysphagia Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness.

Changes in pressure at high altitudes can cause discomfort in the ears. Which structure within the middle ear is instrumental in equalizing pressure?

eustachian tubes Explanation: The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear.

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was dysphagia hoarseness dyspnea weight loss

hoarseness Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal.

The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition?

inflammatory bowel disease Explanation: The nurse stops administering the lavage solution and notifies the physician when the nurse notes that the client has inflammatory bowel disease. Another contraindication for use of lavage solution is intestinal obstruction. Chronic obstructive pulmonary disease (COPD), congestive heart failure, and pulmonary hypertension are not contraindications to administration of lavage solution in preparation for a colonoscopy.

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, blood pressure of 100/80 mm Hg, pulse rate of 88 beats/minute, respiratory rate of 20 breaths/minute, temperature 100° F (37.8° C). What diagnosis will the nurse suspect for this client?

inflammatory bowel disease (IBD) Explanation: IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort. A client with diverticulitis commonly states he has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. What would be an expected finding?

leukocytosis; elevated hematocrit; low sodium, potassium, and chloride Explanation: Tests of serum electrolytes may indicate low levels of sodium, potassium, and chloride. Metabolic alkalosis is evidenced by arterial blood gas results. A complete blood count (CBC) shows an increased WBC count in instances of infection. The hematocrit level is elevated if dehydration develops.

A nurse is obtaining a history from a new client with glaucoma. The client indicates having read about the diagnosis and understanding that this type of glaucoma is due to the degeneration and obstruction of the trabecular meshwork, whose original function is to absorb the aqueous humor. The loss of absorption will lead to an increased resistance, and thus a chronic, painless buildup of pressure in the eye. Which type of glaucoma has the client described?

open angle Explanation: The client described open-angle glaucoma. This type of glaucoma develops painlessly, and visual changes occur slowly. As the IOP rises, it causes edema of the cornea, atrophy of nerve fibers in the peripheral areas of the retina, and degeneration of the optic nerve.

The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience

pain 2 to 3 hours after a meal. Explanation: The client with a duodenal ulcer often awakens between 1 and 2 with pain, and ingestion of food brings relief. Vomiting is uncommon in the client with duodenal ulcer. Hemorrhage is less likely in the client with duodenal ulcer than in the client with gastric ulcer. The client with a duodenal ulcer may experience weight gain.

A nurse is performing focused assessment on her clients. She expects to hear hypoactive bowel sounds in a client with:

paralytic ileus. Explanation: Bowel sounds are hypoactive or absent in a client with a paralytic ileus. Clients with Crohn's disease and gastroenteritis have hyperactive bowel sounds because of increased intestinal motility. A complete bowel obstruction causes absent bowel sounds below the obstruction and hyperactive sounds above the obstruction.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure?

prothrombin time A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising, nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin.

After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms?

retinal detachment Explanation: A detached retina is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery.

When the client tells the nurse that his vision is 20/200 and then asks what that means, the nurse informs the client that a person with 20/200 vision

sees an object from 20 feet away that a person with normal vision sees from 200 feet away. Explanation: The fraction 20/20 is considered the standard of normal vision. Most people can see the letters on an eye chart designated as 20/20 from a distance of 20 feet.

The parent of a young client with severe hearing loss is quite concerned about the child's future independence because of impaired hearing. Which type of hearing loss is usually irreversible?

sensorineural Explanation: Sensorineural hearing loss usually is irreversible.

A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find?

severe abdominal pain with direct palpation or rebound tenderness Explanation: Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (i.e., appendicitis, diverticulitis, ulcerative colitis, a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

Which procedure is performed to examine and visualize the lumen of the small bowel?

small bowel enteroscopy Explanation: Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.

A client has been diagnosed with otosclerosis. The nurse explains to the client that this is a common cause of hearing impairment among adults and is the result of a bony overgrowth of the:

stapes Explanation: Otosclerosis is the result of a bony overgrowth of the stapes and a common cause of hearing impairment among adults.

The nurse is assessing a client for constipation. To identify the cause of constipation, the nurse should begin by reviewing the client's:

usual pattern of elimination. Explanation: Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause.