EXAM 4 ADULT HEALTH FINAL

What intervention should the nurse suggest to a client to prevent nightime Gastroesophageal Reflux disease?

"Elevate the head of the bed 8 to 12 inchesfor sleep."

The nurse teaches the client with Gastroesophageal Reflux Disease about ways to minimize symptoms. Which of the following statements made by the client indicates that more teaching is needed?

"I will be sure to drink cola instead of coffee."

The nurse is advising a client with diverticulitis. Which statement made by the client indicates that additional teaching is needed?

"I will take a senna laxative at bedtime to avoid becoming constipated

A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. All but which of the following statements should the nurse include in this client's discharge teaching?

"It is normal to experience pain and difficulty urinating."

A nurse cares for a young woman with a new ileostomy. The client states, "I cannot have a wedding with an ostomy." How should the nurse respond?

"Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles."

A client with Multiple Sclerosis (MS) asks the nurse to explain the disease. What response by the nurse is the best?

"MS is an autoimmune disorder which causes patchy demyelinization of the nerves."

The nurse is planning discharge teaching for a client who has experienced chronic constipation. Which instructions will the nurse provide to the client?

"Take fiber supplements every day with at least 8 ounces of water."

The nurse cares for a client with Amyotrophic Lateral Sclerosis. The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond?

"What would you like to be done if you begin to have difficulty breathing."

You are caring for a patient who requires discharge teaching on how to maintain a healthy gastrointestinal and urinary system. List 5 items you will include in your teaching for this patient.

1) Increase fluid intake 2) Avoid high amounts of fried food 3) limit alcohol comsumption 4) pee before and after sex 5) take more showers than baths

Which clinical manifestation would serve to alert the nurse to the early onset of Multiple Sclerosis?

Blurry vision, increasing urinary urgency and affected balance

Which of the following is appropriate for a client with irritable bowel syndrome?

Broiled chicken, brown rice, salad and a glass of water

Which of the following preoperative interventions would be contraindicated for the client with acute appendicitis?

Placing the client in a semi-Fowler's position

You are assessing a client with peritonitis. Which clinical manifestations should you expect to find?

Abdominal distention

A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention by the nurse?

Administer an antibiotic.

Which patient education will the nurse provide before discharge for a patient who has had a herniorrhaphy to repair an incarcerated inguinal hernia?

Apply a scrotal support and ice to reduce swelling

A nurse plans care for a client with lower back pain from a work-related injury. Which interventions should the nurse include in this client's plan of care?

Apply moist heat for 20 minutes at least 4 times a day

A 21 year old male reports burning and difficulty with urination. What priority question assists in evaluating the client's concern?

Are you sexually active?"

A client is in the family practice clinic, he is noted to have a weight loss of 12%. What action by the nurse is best?

Ask the client if the weight loss was intentional..

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best?

Assess the client's gag reflex

The nurse is instructing a client diagnosed with a hiatal hernia on ways to reduce the symptoms. Which of the following should be included in these instructions?

Avoid lying down after meals

A client has an nasogastric tube in place for gastric decompression and complains of increasing nausea. Which action should the nurse take first?

Check for proper functioning of the tube

Crohn's disease has the following characteristics. Select all that apply.

Effects the mucosal layer of the GI tract Effects the patient from mouth to anus

You are completing an admission assessment on a patient admitted with a small bowel obstruction (SBO), which of the following you you report to the provider? (Select all that apply)

Emesis prior to insertion of NG tube (NGT). dry mucous membranes

A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following information should the nurse include? (Select all that apply.)

Empty the bladder when there is an urge to void. Take a shower daily. Avoid sitting in a wet bathing suit.

A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin the nurse should instruct the patient to:

Empty the pouch when it is no more than half full

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?

Ensure an adequate airway

All patients with diverticulosis have diverticulitis

False

What potential outcome does the nurse anticipate when administering total parenteral nutrition (TPN)?

Hyperglycemia

The healthcare provider prescribes the following therapies for a client who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first (highest priority)?

Infuse normal saline at 250 mL/hr per order

A nurse contacts the healthcare provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.1 mg/dL. Which action should the nurse recommend?

Intravenous fluids

The nurse caring for a client with Guillain-Barre syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? Select all that apply.

Keep the skin dry and use heel boots Work with nutrition to design a high protein diet Consult with the provider about a physical therapy consult

Which of the following would not be included in a medication regime for a patient being treated for peptic ulcer disease (PUD)?

NSAID

All of the following are examples of tubes that would be used for short term providing of total enteral nutrition, except?

Nasogastric

A client is admitted to the critical care unit with possible Guillain-Barre syndrome. Which symptom of neurologic impairment will require priority nursing interventions? Select all that apply.

New-onset nausea following a position change New adventitious breath sounds Rapid, shallow breathing pattern

Twenty four hours after undergoing a gastric surgery, a patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to?

Notify the surgeon

When the nurse is assessing a patient with Myasthenia Gravis, which action will be the most important to take?

Observe respiratory rate and depth

What action should the nurse in the doctor's office anticipate for a client who has had several episodes of new onset diarrhea from an unknown cause?

Obtain a stool specimen for culture

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow?

Overflow incontinence

You are assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease, which of the following findings are the highest priority?

Patient reports he is having a hard time falling and staying alseep.

Which clinical manifestation of Guillain-Barre Syndrome reflects the most common clinical pattern of the disease?

Progressive, ascending weakness, numbness and tingling of lower extremities

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?

Remind the client that a small amount of bleeding is possible.

A nurse is reviewing the results of a client's urinalysis. The findings indicate the urine is positive for leukocyte esterase and nitrites. Which of the following actions should the nurse take?

Repeat the test early the next morning.

When providing care for a client with Amyotrophic Lateral Sclerosis, the nurse recognizes what as one of the most distressing problems experienced by the client.

Retention of cognitive function with total degeneration of the motor function

You are preparing to discharge a patient that was admitted with peptic ulcer disease (PUD) and bleeding ulcers. You provide education pertaining to behaviors to reduce symptoms that aggravate PUD. What teaching do you provide? Select all that apply.

Sit upright 30-60 minutes after meals H. pylori can be a concern in patients with peptic ulcers The goal of initial intervention is to control symptoms and prevent further complications Extreme vomiting should be reported to your health care provider

The nurse is caring for a client with a diagnosis of Multiple Sclerosis. The client is concerned about the recurrent exacerbations and fatigue. The nurse suggests which of the following interventions to help?

Space activities throughout the day with opportunities for rest

The client returns to the nursing unit postoperatively after a colostomy. Which of the following assessments would require immediate action by the nurse?

Stoma is bluish in color

A nurse is doing a nursing assessment on a patient with chronic constipation. What data obtained during the interview may be a factor contributing to the constipation?

Suppressing the urge to defecate while at work

The nurse notes a bulge in the client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings?

The client has a reducible inguinal hernia

The symptoms of severe ulcerative colitis include:

The client may have >20 bloody stools per day

The following test values are returned for a client. Serum BUN 18 mg/dL and Serum Creatinine 1.0 mg/dL. These findings demonstrate?

The creatinine is high, and the BUN is high

A nurse assesses a patient to have a rolling hiatal hernia when they present with symptoms of a feeling of fullness and breathlessness after eating, and chest pain like angina, particularly when in a recumbent position.

True

The tensilon test (ACTH injection) is used as a positive indicator for the disease of myasthenia gravis?

True

A patient is newly admitted to the acute medical care unit. Which laboratory results would support a diagnosis of malnutrition?

decreased Pre albumin of 13 mg/dL

A nurse reviews a client's laboratory results. Which results from the client's urinalysis should the nurse identify as normal? (Select all that apply).

pH 6.0 Glucose negative Specific gravity: 1.015

A herniated disc can cause severe burning or stabbing pain down into the leg or foot due to compression on the __________ nerve.

sciatic