ADN 140 UNIT 3

A client is admitted with the diagnosis of acute pancreatitis. Which clinical manifestation would the nurse associate with this diagnosis? Select all that apply. One, some, or all responses may be correct. -Cyanosis -Acute pain -Vomiting -Weight loss -Decreased lipase -Hypertension -Hypoglycemia -Increased amylase

-Acute Pain -Vomiting -Weight loss -Increased Amylase

The nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestation would the nurse associate with the client's condition? Select all that apply. One, some, or all responses may be correct. -Ascites -Hunger -Pruritus -Jaundice -Headache -Vomiting -Bruising -Anorexia

-Ascites -Pruritus -Jaundice -Vomiting -Bruising -Anorexia

A client is scheduled for a barium swallow. How would the nurse prepare the client for the test? Select all that apply. One, some, or all responses may be correct. -Ask about allergies to iodine before the procedure. -Clarify procedural questions before the consent is signed. -Administer cleansing enemas before the test. -Suggest a light breakfast on the day of the procedure. -Ensure that a laxative is prescribed after the test. -Instruct to withhold prescribed opioids for 1 day before the test. -Assess the client's ability to swallow. -Ensure the bowel is adequately cleansed.

-Clarify procedural questions before the consent is signed. -Ensure that a laxative is prescribed after the test. -Instruct to withhold prescribed opioids for 1 day before the test. -Assess the client's ability to swallow. Rationale: Before the procedure the nurse should ensure the consent is signed and clarify any remaining concerns or questions. Barium will harden and may lead to constipation and a possible impaction; a laxative and increased fluids promote elimination of barium. Opioids are withheld for 24 hours before the test to prevent intestinal immobility. The radiologist should be notified prior to the test if the client has a tendency to aspirate. Iodine is not used with a barium swallow test. Administering cleansing enemas before the test is not part of the preparation; feces in the lower gastrointestinal (GI) tract will not interfere with visualization of the upper GI tract. The client is kept to nothing by mouth 8 to 12 hours before the test to ensure that the upper GI tract is free of food. In addition, a low-residue diet may be prescribed several days before the test. The barium enema, not barium swallow, visualizes the lower GI tract which requires stool to be clear and the nurse would ensure the bowel is adequately cleansed prior to testing.

Which finding indicates that a client is at an increased risk for colorectal cancer (CRC)? Select all that apply. One, some, or all responses may be correct. -Presence of dark, tarry stools -Family history of polyposis -20-year history of ulcerative colitis -Use of caffeine or coffee -Unintentional 20-pound weight loss -Change in bowel pattern for 3 months -Long-term use of NSAIDS such as ibuprofen -Bacterial infection with H. pylori

-Dark and tarry stools -a family history of polyposis -a 20-year history of ulcerative colitis -unintentional weight loss of 20 pounds -a change in bowel patterns lasting 3 months are all findings that would warrant further evaluation for CRC.

Which information will the nurse include when teaching the client about ostomy care? Select all that apply. -Explain what an ostomy is and how it functions -Decrease fluid intake to 1500 mL/day -Empty the pouch when it is ½ full -The stoma should be pink to red in color -Keep the area around the stoma clean and dry -Foods to avoid -A skin barrier should be used before applying the pouch -Fecal continence is possible

-Explain what an ostomy is and how it functions -The stoma should be pink to red in color -Keep the area around the stoma clean and dry -Foods to avoid -A skin barrier should be used before applying the pouch Rationale: When providing education about an ileostomy the nurse would explain what an ostomy is and how it functions. The stoma should remain pink to red in color. A dusky blue stoma indicates ischemia. The areas around the stoma should be kept clean and dry. The nurse would include foods to avoid in client teaching. A skin barrier should be used before applying the pouch to protect the surrounding skin from irritation. Since bowel sounds are absent, peristalsis is not occurring and output would be negligible. After several days, an ileostomy will start producing liquid type stool thus increasing the risk for dehydration. Therefore, fluid intake should be increased to 2 to 3 L per day (not limited to 1500 mL/day). The pouch should be emptied when it is no more than 1/3 full (not ½ full) to decrease risk of skin irritation and leakage. Fecal continence is not possible because ileostomies cannot be regulated.

Which clinical finding leads the nurse to conclude that an IV has infiltrated rather than caused inflammation? a. pain b. coolness c. localized swelling d. cessation in flow of solution

b. coolness

Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer? a. the pain intensifies after vomiting stomach contents b. the pain occurs 1-2 hrs after having a meal c. the pain increases when ingesting an excess of fatty foods d. the pain begins in the epigastrium and radiates to the abdomen

b. the pain occurs 1-2 hours after having a meal

Which explanation would the nurse provide to a client with gastric ulcer disease who asks the nurse why the hcp has prescribed metronidazole? a. to augment the immune response b. to potentiate the effect of antacids c. to treat helicobacter pylori infection d. to reduce hydrochloric acid secretion

c. to treat helicobacter pylori infection

Which autoantigens are responsible for the development of Crohn's Disease?

crypt epithelial cells

When educating a client with interstitial cystitis, which food would the nurse mention is a bladder irritant? Select all that apply. One, some, or all responses may be correct. Milk White chocolate Citrus fruit Aged cheeses Cottage cheese Green, leafy vegetables Bananas Melons Tomatoes

Citrus fruits, aged cheeses, and acidic vegetables such as tomatoes can irritate the bladder of some individuals. Milk, white chocolate, cottage cheese, green, leafy vegetables, and non-acidic fruits such as bananas and melons are not likely to irritate the bladder.

Which explanation would the nurse provide for administering prednisone to a client with an exacerbation of colitis?

Although the medication decreases intestinal inflammation, it will not cure the colitis.

By which process would total parenteral nutrition TPN on an outpatient basis help a client with Crohn's disease prepare for surgery?

Decreasing fecal bulk

Which strategy would the nurse include in the client's plan of care regarding preventing the development of ureteral colic from renal calculi in the future? a. instruct the client to drink at least 3 L of fluid daily b. suggest interventions to decrease the serum creatinine level c. establish a urinary output goal of 2000 mL per 24 hrs d. teach the client to exclude milk products from their diet

a. Instruct the client to drink at least 3 L of fluid daily