Exam 3 Review

the clients diagnosed with a gunshot wound to the head assumes decorticate pOsturing when the nurse applies painful stimuli. Which assessment data obtained 3 hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 millimeters in size and nonreactive to painful stimuli.

1. purposeless movement indicates that the clients cerebral edema is decreasing. The best motor responses purposeful movement, but purpose less movement indicates an improvement over the Decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

the 29-year-old client that was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after 3 months and has cognitive deficits. Which goal would be more realistic for this client? 1. The client will return to work within 6 months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain power and bladder control.

2 . Cognitive pertains to mental processes of comprehension, judgment, memory, and reasoning.

The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. Restrict fluids to 1,000 mL/ 24 hours. 2. Drink 400 to 500 mL with each meal. 3. Drink fluids midmorning, midafternoon, and late afternoon. 4. Attempt to void at least every 2 hours 5. Use intermittent catheterization as needed.

2,3,4,5

Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? 1. Increased preference for foods high in salt. 2. Eating food on only half of the plate. 3. Forgetting the names of foods. 4. Inability to swallow liquids.

2. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods would be aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

The female nurse sticks herself with a contaminated needle. which action should the nurse implement first. 1. notify the infection control nurse 2. cleanse the area with soap and water 3. request postexposure prophylaxis 4. check the hepatitis status of the client

2. cleanse the area with soap and water: the nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? 1. Limit fluid intake to 1,000 mL/ day. 2. Insert an indwelling urinary catheter. 3. Establish a regular voiding schedule. 4. Administer prophylactic antibiotics, as ordered.

3

The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note: 1. A postictal state of amnesia. 2. An hallucination that occurs during a seizure. 3. A symptom that occurs just before a seizure. 4. A feeling of relaxation as the seizure begins to subside.

3. An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (e.g., an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur before a seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.

3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.

3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

Which of the following is contraindicated for a client with seizure precautions? 1. Encouraging him to perform his own personal hygiene. 2. Allowing him to wear his own clothing. 3. Assessing oral temperature with a glass thermometer. 4. Encouraging him to be out of bed.

3. Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed.

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/ 88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? 1. Suction the airway 2.hyperoxygenate 3.suction the mouth 4. Provide sedation

4,2,1,3

A female college student goes to the university health clinic complaining of pain that started at the umbilicus and moved to the right lower quadrant over the last 12 hours. You notice muscle guarding on examination. What action should you take? A. Administer a PRN laxative per standing orders. B. Ask about the last menstrual period. C. Make the student NPO. D. Assess bowel sounds.

C. Make the student NPO. This is a classic description of appendicitis. At the very least, it is an acute abdomen, and the student should be kept NPO until a need for surgery is ruled out. The student should be referred to an emergency department.

The nurse is caring for the following clients. Which client what the nurse assess first after receiving the shift report? 1. The 22 year old male client diagnosed with a concussion who is complaining someone is waking him up every 2 hours. 2. The 36 year old female client admitted with complaints of left sided weakness who is scheduled for an MRI scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with CVA who has expressive aphasia.

3. The Glasgow Coma Scale is used to determine a client's response to stimuli such asEye opening response, best verbal response, and best motor response secondary to a neurological problem scores range from 3 which is a deep coma to 15 which is intact neurological function. A client with a score of 6 should be assessed first.

the client with an acute exacerbation of chronic pancreatitis has a nasogastric tube. which interventions should the nurse implement? select all that apply 1. monitor the clients bowel sounds 2. monitor the clients food intake 3. assess the clients intravenous site 4. provide oral and nasal care 5. monitor the clients blood glucose

1, 3, 4, 5: the return of bowel sounds indicates the return of peristalsis, and the nasogastric suction is usually discontinued within 24 to 48 hrs thereafter. the nurse should assess for signs of infection or infiltration. fasting and the ng tube increase the clients risk for mucous membrane irritation and brk dwn. blood glucose levels are monitored because clients with chronic pancreatitis can develop diabetes mellitus

Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.

1. A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage.

3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? 1. Early in the morning, when the client's energy level is high. 2. To coincide with the peak action of drug therapy. 3. Immediately after a rest period. 4. When family members will be available.

.2. Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are managed with drug therapy.

An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: 1. Myexdema coma 2.Thyroid storm 3. cretinism 4. hashimoto's

1. myedema coma

. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate? 1. Maintaining an upright position. 2. Restricting the diet to liquids until swallowing improves. 3. Introducing foods on the unaffected side of the mouth. 4. Keeping distractions to a minimum.

2. A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.

2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

Which of the following is an initial sign of Parkinson's disease? 1. Rigidity. 2. Tremor. 3. Bradykinesia. 4. Akinesia.

2. The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and brady-kinesia is the third sign. Akinesia is a later stage of bradykinesia.

The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation? 1. Impaired mobility related to spasticity and fatigue. 2. Risk for falls related to muscle weakness and sensory loss. 3. Risk for seizures related to muscle tremors and loss of myelin. 4. Impaired skin integrity related bowel and bladder incontinence.

3

The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order? 1. Maintain patent airway 2. record the seizure activity observed 3.ease the client to the floor 4. Obtain vital signs

3,1,4,2

What is the priority nursing intervention in the postictal phase of a seizure? 1. Reorient the client to time, person, and place. 2. Determine the client's level of sleepiness. 3. Assess the client's breathing pattern. 4. Position the client comfortably.

3. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas. 2. Vacant staring and abruptly ceasing all activity. 3. Facial grimaces, patting motions, and lip smacking. 4. Loss of consciousness, body stiffening, and violent muscle contractions.

4. A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug 1. Dysuria 2. leg cramps 3. blurred vision 4 . tachycardia

4. tachycardia

A patient with a history of peptic ulcer disease has presented to the emergency department with complaints of severe abdominal pain and a rigid, boardlike abdomen, prompting the health care team to suspect a perforated ulcer. Which of the following actions should the nurse anticipate? A) Providing IV fluids and inserting a nasogastric tube B) Administering oral bicarbonate and testing the patient's gastric pH level C) Performing a fecal occult blood test and administering IV calcium gluconate D) Starting parenteral nutrition and placing the patient in a high-Fowler's position

A) Providing IV fluids and inserting a nasogastric tube -->A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis and parenteral nutrition is not a priority in the short term.

What is a classic diagnostic finding in a patient with appendicitis? A. Elevated white blood cell (WBC) count B. Elevated level of lipase C. Left lower quadrant tenderness D. Positive Kernig's sign

A. Elevated white blood cell (WBC) count. The WBC count is mildly to moderately elevated in about 90% of cases. The classic location for appendicitis is McBurney's point in the right lower quadrant.

A patient is suspected of having a large intestine obstruction. What is the best indication that an obstruction is present? A. Lack of flatus B. Nausea C. Temperature of 100.4° F (38° C) D. Thirst

A. Lack of flatus Inability to pass gas or constipation is a common manifestation of a large intestinal obstruction.

The nurse is caring for a patient treated with intravenous fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, the nurse understands that which of the following food choices would be most appropriate? A) Ice tea B) Dry toast C) Warm broth D) Plain hamburger

B) Dry toast (Dry toast or crackers may alleviate the feeling of nausea and prevent further vomiting. Extremely hot or cold liquids and fatty foods are generally not well tolerated.)

A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: A. 2-4 hours after administration B. 6-14 hours after administration C. 16-18 hours after administration D. 18-24 hours after administration

B. 6-12 hours after administration

Which is correct information about the treatment of Crohn's disease? A. Surgery is the preferred treatment. B. Aminosalicylates are frequently used first. C. Corticosteroids are given for long-term therapy. D. High-fiber foods are encouraged to add bulk to diarrheal stool.

B. Aminosalicylates are frequently used first. Aminosalicylates (5-ASAs) are used first because they are less toxic, although there is a movement to using biologic and targeted therapy as first-line therapy. Drugs with 5-ASA suppress the proinflammatory cytokines and inflammatory mediators.

What is the main treatment for a patient with acute diverticulitis? A. Colon resection and ostomy B. Nasogastric tube and intravenous (IV) fluids C. Long-term course of oral corticosteroids D. Mechanical soft diet

B. Nasogastric tube and intravenous (IV) fluids. In acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. Bowel rest can be accomplished with the use of a nasogastric tube and IV fluids.

Which is a complication in patients with ulcerative colitis? A. Hyperkalemia B. Toxic megacolon C. Pancreatitis D. Barrett's esophagus

B. Toxic megacolon. Colonic dilation (toxic megacolon) can occur as a result of decreased tissue function, with lack of peristalsis and enlargement of the colon. The patient is at risk for perforation.

Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: A. Hypotension. B. Thick, coarse skin. C. Deposits of adipose tissue in the trunk and dorsocervical area. D. Weight gain in arms and legs

C. deposits of adipose tissue in the trunk and dorsocervical area

When a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS), the nurse's priority is to provide: A. Oxygen B. Carbohydrates C. Fluid replacement D. Dietary instruction

C. fluid replacement

A patient is admitted to the hospital with a diagnosis of Cushing syndrome. On physical assessment of the patient, the nurse would expect to find a. HTN, peripheral edema, and petechiae b. weight loss, buffalo hump, and moon face with acne c. abdominal and buttock striae, truncal obesity, and hypotension d. anorexia, signs of dehydration, and hyper pigmentation of the skin

a. HTN, peripheral edema, and petechiae (rationale- The effects of glucocorticoid excess include weight gain from accumulation and redistribution of adipose tissue, sodium and water retention, glucose intolerance, protein wasting, loss of bone structure, loss of collagen, and capillary fragility. Clinical manifestations of corticosteroid deficiency include hypotension, dehydration, weight loss, and hyperpigmentation of the skin.)

which client problem has priority for the client dx with acute pancreatitis? 1. risk for fluid volume deficit 2. alteration in comfort 3. imbalanced nutrition: less than body requirements 4. knowledge deficit

alteration in comfort: autodigestion of the pancreas results in severe epigastric pain, accompanied by nausea, vomiting, abdominal tenderness and muscle guarding

the client is admitted to the medical dept. with a dx of r/o acute pancreatitis. which laboratory values should the nurse monitor to confirm this dx? 1. creatinine and BUN 2. troponin and CK-MB 3. serum amylase and lipase 4. serum bilirubin and calcium

serum amylase and lipase: serum amylase increases within 2 to 12 hrs of the onset of acute pancreatitis to 2 to 3 times normal and returns to normal in 3 to 4 days; lipase elevates and remains elevated for 7 to 14 days

the client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2x2 Gauze under the nose to collect drainage.

3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid and the HCP should be notified immediately.

Knowing that gluconeogenesis helps to maintain blood levels, a nurse should: A. Document weight changes because of fatty acid mobilization B. Evaluate the patient's sensitivity to low room temperatures because of decreased adipose tissue insulation C. Protect the patient from sources of infection because of decreased cellular protein deposits D. Do all of the above

D. all of the above

the nurse is caring for a client diagnosed with epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93 percent. 4. Perform deep Nasal suction every 2 hours. 5. Administer mild sedative.

correct answers 2, 3,5. Stool softeners are initiated to prevent the Bell sell the maneuver which increaseS ICP. oxygen saturation higher the 93 percent ensures oxygenation of the brain tissues. decreasing oxygen levels increase cerebral edema.mild sedative will reduce the clans agitation. Strong narcotics would not be administered because they decrease the clients loc.

A patient with Grave's dz asks the nurse what caused the disorder. The best response by the nurse is a. "The cause of Grave's disease is not known, although it is thought to be genetic. b. "It is usually associated with goiter formation from an iodine deficiency over a long period of time." c. "Antibodies develop against thyroid tissue and destroy it, causing a deficiency of thyroid hormones" d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones.

d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones."(rationale- The antibodies present in Graves' disease that attack thyroid tissue cause hyperplasia of the gland and stimulate TSH receptors on the thyroid and activate the production of thyroid hormones, creating hyperthyroidism. The disease is not directly genetic, but individuals appear to have a genetic susceptibility to become sensitized to develop autoimmune antibodies. Goiter formation from insufficient iodine intake is usually associated with hypothyroidism.)

Causes of primary hypothyroidism in adults include a. malignant or benign thyroid nodules b. surgical removal or failure of the pituitary gland c. surgical removal or radiation of thyroid gland d. autoimmune-induced atrophy of the gland

d. autoimmune-induced atrophy of the gland (rationale- both Graves disease and Hasimotos thyroiditis are autoimmune disorders that eventually destroy the thyroid gland, leading to primary hypothyroidism. Thyroid tumors most often result in hyperthyroidism. Secondary hypothyroidism occurs as a result of pituitary failure, and iatrogenic hypothyroidism results from thyroidectomy or radiation of the thyroid gland.)

the nurse is discussing complications of chronic pancreatitis with a client dx with the disease. which complication should the nurse discuss with the client? 1. diabetes insipudus 2. crohns disease 3. narcotic addiction 4. peritonitis

narcotic addiction: its related to the frequent, severe pain episodes often occurring with chronic pancreatitis which require narcotics for relief

65. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease? 1. To cure the disease. 2. To stop progression of the disease. 3. To begin preparations for terminal care. 4. To maintain optimal body function.

4. Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. Many clients live for years with the disease, however, and it would not be appropriate to start planning terminal care at this time.

the client is dx with acute pancreatitis. which health care providers admitting order should the nurse question? 1. bedrest with bathroom privleges. 2. initiate iv therapy of D5W at 125 mL/hr 3. weigh client daily 4. low fat, low carb diet

4. low fat, low carb diet: the client will be NPO, which will decrease stimulation of the pancreatic enzymes, resulting in decreased autodigestion of the pancreas, therefore decreasing pain

The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which of the following teaching points should the nurse provide to the patient in light of his new diagnosis? A) "You'll need to drink at least two to three glasses of milk daily." B) "It would likely be beneficial for you to eliminate drinking alcohol." C) "Many people find that a minced or pureed diet eases their symptoms of PUD." D) "Your medications should allow you to maintain your present diet while minimizing symptoms."

B) "It would likely be beneficial for you to eliminate drinking alcohol." Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD and alcohol is best avoided because it can delay healing.

The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 ml PO. The nurse would evaluate its effectiveness by questioning the patient as to whether which of the following symptoms has been resolved? A) Diarrhea B) Heartburn C) Constipation D) Lower abdominal pain

B) Heartburn (Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of GI discomfort, such as with heartburn associated with GERD.)

Following administration of a dose of metoclopramide (Reglan) to the patient, the nurse determines that the medication has been effective when which of the following is noted? A) Decreased blood pressure B) Absence of muscle tremors C) Relief of nausea and vomiting D) No further episodes of diarrhea

C) Relief of nausea and vomiting.(Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve).

Which of the following methods of insulin administration would be used in the initial treatment of hyperglycemia in a client with diabetic ketoacidosis? A. Subcutaneous B. Intramuscular C. IV bolus only D. IV bolus, followed by continuous infusion

D

For a patient with Crohn's disease which assessment finding is most important for you to follow-up? A. Bloody diarrheal stool: 4 times/day B. Abdominal cramping C. Temperature: 100.4° F (38° C) D. Positive rebound tenderness

D. Positive rebound tenderness. Positive rebound tenderness is a classic sign of peritonitis and requires emergency follow-up. The other options are expected signs or symptoms with ulcerative colitis, which has intermittent exacerbations.

Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? 1. Double vision. 2. Sudden bursts of energy. 3. Weakness in the extremities. 4. Muscle tremors.

2

In planning care for the patient with Crohn's disease, you recognize that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease A. frequently results in toxic megacolon. B. causes fewer nutritional deficiencies than does ulcerative colitis. C. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy. D. is manifested by rectal bleeding and anemia more frequently than is ulcerative colitis.

C. often recurs after surgery, whereas ulcerative colitis is curable with a colectomy. Because there is a high recurrence rate after surgical treatment of Crohn's disease, medications are the preferred treatment.