PrepU Med surg assignment 16
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation?
"How many alcoholic drinks do you typically consume in a week?"
A patient with end-stage liver disease who is scheduled to undergo a liver transplant tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient?
"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs."
A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply.
-Administering diuretics -Implementing fluid restrictions -Enhancing patient positioning
A nurse is reviewing laboratory test results from a client. The report indicates that the client has jaundice. What serum bilirubin level must the client's finding exceed? Enter the correct number only.
2.5
A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function?
30 mg/dL
A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis?
A 39-year-old man with chronic alcoholism
The nurse is educating a patient with cirrhosis about the importance of maintaining a low-sodium diet. What food item would be permitted on a low-sodium diet?
A pear
Common clinical manifestations of Crohn's disease include:
Abdominal pain and diarrhea.
A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?
Acute pain
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
A patient arrives in the emergency department with complaints of right lower abdominal pain that began 4 hours ago and is getting worse. The nurse assesses rebound tenderness at McBurney's point. What does this assessment data indicate to the nurse?
Appendicitis
A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting?
Apply a skin barrier to the peristomal skin prior to applying the pouch.
An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform?
Assess the patient's food and fluid intake.
A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient's family how to safely perform which of the following actions?
Assessing the patency of the drainage catheter
The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?
Asterixis
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
Which of the follow statements provide accurate information regarding cancer of the colon and rectum?
Cancer of the colon and rectum is the second most common type of internal cancer in the United States.
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.
Which of the following is clinical manifestation of cholelithiasis?
Clay-colored stools
Which of the following laxatives should be used by a cardiac patient who should avoid straining?
Colace
A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the patient's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
Contact the primary care provider promptly and report these signs of perforation.
Which of the following would be the most important nursing assessment in a patient diagnosed with ascites?
Daily weight and measurement of abdominal girth
A 70-year-old patient 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 of the following gerontologic considerations associated with the pancreas?
Decreases in the physiologic function of major organs
A client is being treated for diverticulosis. Which of the following points should the nurse include in this client's teaching plan? Select all that apply.
Do not suppress the urge to defecate. Drink at least 8 to 10 large glasses of fluid every day.
A nurse is assessing a patient's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
Document that the stoma appears healthy and well perfused.
A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?
Drink at least 8 to 10 large glasses of fluid every day
A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan?
Drink at least 8 to 10 large glasses of fluid every day.
The nurse is teaching a patient with an ostomy how to change the pouching system. Which of the following should the nurse include in the teaching of a patient with no peristomal skin irritation?
Dry skin thoroughly after washing
The nurse is performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening?
Familial polyposis
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
A nurse is preparing a client for surgery. During preoperative teaching, the client asks where is bile stored. The nurse knows that bile is stored in the:
Gallbladder
Diet therapy for patients diagnosed with IBS include which of the following?
High-fiber diet
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
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia?
Hypotension
Crohn's disease is a condition of malabsorption caused by which of the following pathophysiological processes?
Inflammation of all layers of intestinal mucosa
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
Irritability and drowsiness
The nurse is conducting a community education program on colorectal cancer. Which of the following statements should the nurse include in the program?
It is the third most common cancer in the United States.
A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?
Lack of free water intake
A nurse is reviewing lab results for a client with an intestinal obstruction, and infection is suspected. Which of the following would be an expected finding?
Leukocytosis; elevated hematocrit; low sodium, potassium, and chloride
A physician has ordered a liver biopsy for a client whose condition is deteriorating. Which of the following places the client at high risk due to her altered liver function during the biopsy?
Low platelet count
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.
A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
Polyps
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response?
Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.
The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?
Respiratory assessment related to increased thoracic pressure
The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation? Choose the correct option.
Review the client's usual pattern of elimination
Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency?
Scurvy
A patient comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out possible acute pancreatitis. The nurse would expect the diagnosis to be confirmed with which of the following elevated laboratory tests?
Serum amylase
Effie Geitgey, a 93-year-old retired waitress, obsesses about the regularity of her bowel movements (a common obsession among the residents of the long-term care facility where you practice nursing). In your frequent (seems like daily) client education sessions, you reinforce the medically acceptable definition of "regularity". What is the actual measurement of "regular"?
Stool consistency and client comfort are the proper measurements
The nurse is caring for a client who has undergone surgery for a liver disorder. The client is at risk for fluid loss. What should a nurse closely monitor to determine the presence of decreased intravascular volume in the client?
The client's serum sodium levels
The presence of mucus and pus in the stools suggests which of the following conditions?
Ulcerative colitis
The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?
Usual pattern of elimination
Which of the following medications is used to decrease portal pressure, halting bleeding of esophageal varices?
Vasopressin (Pitressin)
Barbara Allen, a 69-year-old retired cab driver, is undergoing diagnostics in the hospital where you practice nursing. She has been experiencing lower GI difficulties and has reached the point where she needs direction. With all the trouble she's been having with her lower bowel, what function being affected most by her disorder?
Water and electrolyte absorption
A longitudinal tear or ulceration in the lining of the anal canal is termed a (an)
anal fissure.
A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:
anorexia, nausea, and vomiting.
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:
cirrhosis
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
yellow sclerae.