AH1 EAQS Test 4
The nurse is performing a health history and physical assessment of a client with Cholelithiasis and obstructive jaundice. Which clinical finding would the nurse expect the client to exhibit?
pain in the right upper quadrant
A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, which would the nurse expect to observe?
Steatorrhea ( soft, frothy, foul smelling)
Which clinical manifestation does the nurse expect the client to report when admitted for surgical resection of a rectosigmoid colon cancer? SELECT ALL THAT APPLY
feeling tired, rectal bleeding, change in shape of stool, feeling of abdominal bloating
A client is hospitalized with a diagnosis of acute pancreatitis. The plan of care is focused on the goals of maintaining nutrition, promoting rest, maintaining fluids and electrolytes, and decreasing anxiety. Which interventions would the nurse implement? ALL THAT APPLY
Administer analgesics teach relaxation exercises Monitor cardiac rate and rhythm
Which finding indicates that a client is at an increased risk for colorectal cancer?
All of the Above
The nurse reviews the lab results of a client with acute pancreatitis. Which test is significant in determining the client's response to treatment?
Amylase Level
The nurse is teaching a group of adults about the signs and symptoms of colorectal cancer. Which common manifestations would the nurse include in the teaching program. SELECT ALL THAT APPLY
Anemia, Rectal Bleeding, and change in bowel habits.
Which clinical indicator would the nurse review before scheduling a client for an endoscopic retrograde cholangiopancreatography? (ERCP)
Bilirubin Level
Which pathophysiological rationale explains why a client who is 4 days postabdominal surgery has not passed flatus and has hypoactive bowel sounds and why a paralytic ileus is suspected of developing?
Impaired neural functioning
For which clinical indicator would the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? SELECT ALL THAT APPLY
Dark Urine Yellow Skin Clay-colored stool
Clinical manifestations would the nurse expect from a client with Ulcerative Colitis? ALL THAT APPLY
Fever diarrhea abdominal cramps
Which nursing intervention would be included in the plan of care of a client with liver cancer and ascites who is scheduled for a paracentesis?
Having the client void before the procedure.
A client is hospitalized with acute pancreatitis. Which would be included in the patient's care plan?
IV Fluids
A client develops an intestinal obstruction. A NGT is inserted and connected to low, continuous suction. The nurse monitors the client for fluid volume deficit. Which clinical finding would the nurse expect if the client becomes dehydrated?
Inelastic Skin turgor
The nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "How does my drinking relate to my diagnosis?" Which effect of alcohol would the nurse include when responding?
It increases enzyme secretion and pancreatic duct pressure that causes back flow of enzymes into the pancreas
Which antidiarrheal medication would the nurse anticipate administering to a client with severe diarrhea who is prescribed IV Fluids, sodium bicarbonate, and an antidiarrheal medication?
Loperamide (inhibits peristalsis)
A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. What type of stool should the nurse expect?
Moist and formed
A client is admitted to the hospital for the surgical repair of an incarnated (irreducible) indirect inguinal hernia. Which is the priority preoperative nursing intervention for this client?
Observing the client's bowel movements.
The nurse is caring for a client who has cancer of the rectum and is scheduled for an abdominoperineal resection with creation of a colostomy. For which type of surgery would the nurse prepare the client?
Permanent sigmoid colostomy
A client with an obstruction of the pancreatic duct is diagnosed with acute pancreatitis. A subtotal pancreatectomy is performed. The nurse would monitor the client for which post op complication?
Paralytic ileus
The nurse id caring for a client with chronic inflammation of the bowel. for which most serious complication would the nurse monitor in this client?
Perforation (hole in abdominal wall)
A client with sever Crohn disease develops a small bowel obstruction. Which clinical finding would the nurse expect the client to report?
Projectile vomiting
Acute appendicitis develops in an older client with a history of chronic constipation. Before arrival at the hospital, the client attempted self-care at home.
Self Administering a small-volume enema
A client is worried about what to expect after having a pancreatoduodenectomy (whipple) for cancer of the pancreas. In helping this client plan for the future, which concept would the nurse need to understand?
Stage and Grade of the client's cancer
During a routine physical, a 50 yr old client asks why a tool specimen for occult blood testing was prescribed. Which response would the nurse utilize?
Starting at your age, this test is performed routinely as part of an assessment for solon cancer.
A client with ulcerative colitis has experienced frequent severe exacerbations over the past several years. The client is admitted to the hospital with intense pain, severe diarrhea, and cachexia(weakness). Which therapeutic course would the nurse expect the HCP to explore with this patient?
Surgical therapy (Colectomy)
Three days before surgery for a permanent colostomy because of cancer of the colon, a client is receptive to all procedures, responds pleasantly when approached and does not question the staff about interventions or care being received. Which conclusions should the nurse make based on these behaviors.
The client is not fully verbalizing feelings about concerns.
A client admitted to the hospital with Laennec cirrhosis and chronic pancreatitis. Bile salts are prescribed, and the client ask why they are needed. How would the nurse respond?
They aid in the absorption of fat soluble vitamins
A client with a history of pancreatitis is scheduled for a surgery to excise a pseudocyst of the pancreas. The client asks, " what is a pseudocyst?" Which info would the nurse include in a response to this question?
Walled- off space of pancreatic enzymes and exudate
A client with a newly formed colostomy, secondary to cancer of the rectum, received instructions regarding ostomy care and management. Which client statement indicated understanding of colostomy care?
I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma.
The postoperative diet prescription for a client with a colostomy states, "diet as tolerated." Which principle would the nurse include in the teaching plan to guide the client's food choices.
returning to a regular diet as soon as possible promotes physical rehabilitation
Which Information about malignant tumors of the colon would the nurse consider when providing care for a client with an obstruction of the colon.
Colon obstructions are usually malignant
A client has a surgical creation of a colostomy for cancer of the rectum. The client asks, What's the difference between irrigating a colostomy and having an enema? The nurse should differentiae between the two procedures by explaining that the colostomy irrigation procedure involves which step.
using a cone shaped tip catheter
The nurse provides postoperative teaching about colotomy care to a client who underwent surgery for cancer of the colon. The education would include which instruction related to skin care around the stoma.
wash the area with soap and water and then apply a protective ointment
A client with acute gastritis secondary to alcoholism and cirrhosis reports frequent nausea, pain that increases after meals, and black tarry stools. The client recently joined AA. The nu8rse would give priority to which client history item?
Black, Tarry Stools
which condition is it most important for the nurse to assess for in a client admitted to the hospital for acute gastritis and ascites secondary to alcohol use and cirrhosis
Blood in stool
A client who is obese and has a history of alcohol abuse is admitted to the hospital with a diagnosis of acute pancreatitis. Which is an appropriate initial client treatment goal?
decrease pain
A client with cirrhosis of the liver is scheduled to have a paracentesis. Which intervention would the nurse do to prepare the client for the procedure?
Instruct the client to void
Which nursing assessment would help confirm the diagnosis of intussusception.
observing characteristics of stools
After numerous diagnosis test, a client with jaundice receives the diagnosis of pancreatic cancer. Which rationale explains the cause of the client's jaundice?
obstruction of the common bile duct by pancreatic neoplasm
Assessment findings of a client who is admitted to the ER include cramping pain in the left lower quadrant, weakness, bloating, malaise, and low grade fever. The nurse suspects which condition?
Diverticulitis
Which action would the nurse include in the plan of care for a client admitted with peritonitis secondary to a ruptured appendix
Inserting a nasogastric tube
After surgery for cancer of the pancreas, the client's nutrition and fluid regimen are influenced by the remaining amount of functioning pancreatic tissue. The nurse considers both the exocrine and endocrine functions of the pancreas and expects that, postoperatively, the client's dietary regimen will be focused on the management of which substances?
Fats and Carbs
Which statement is important for the nurse to include in the teaching plan of a client with irritable bowel syndrome who has instructions to tale psyllium for constipation
each dose should be taken with a full glass of water or juice
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life threatening complication would the nurse assess the client after this surgery?
limited water absorption caused by removal of intestine
Which rationale will the nurse provide to a client with Crohn's disease who asks why the prescribed vitamins have been given IV rather than by mouth? ALL THAT APPLY
more rapid action results oral are less effective Intestinal absorption may be inadequate
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? ALL THAT APPLY
rebound tenderness diminished bowel sounds rigid, board like abdomen
An older client's colonoscopy reveals presence of extensive diverticulosis. Which type of diet would the nurse encourage the client to follow?
High Fiber (fiber promotes passage of residue through the intestine thereby preventing constipation)
The nurse provided dietary teaching for a client with a colostomy. Which response by the client is indicative of successful learning?
I can eat everything I ate before the operation but avoid foods that cause gas.
A client returns from from surgery with a permanent colostomy. During the first 24 hours, the colostomy would not drain, Which would the nurse determine is the probable cause of this response, and which is the corresponding treatment.
absence of gastrointestinal motility: continue to monitor
