Exam 4
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome would be appropriate for this client? 1. The client has conscious control over bladder activity. 2. The client's bladder does not become overdistended. 3. The client has bladder sensation and no discomfort. 4. The client is able to check for bladder location in relation to the umbilicus.
2. The client's bladder does not become overdistended.
The nurse is caring for a client diagnosed with rule out nephrotic syndrome. Which intervention should be included in the plan of care? 1. Monitor the urine for bright-red bleeding. 2. Evaluate the calorie count of the 500-mg protein diet. 3. Assess the client's sacrum for dependent edema. 4. Monitor for a high serum albumin level
3. Assess the client's sacrum for dependent edema.
The elderly client is diagnosed with chronic glomerulonephritis. Which lab value indicates the condition has gotten worse? 1. The BUN is 15 mg/dL. 2. The creatinine level is 1.2 mg/dL. 3. The glomerular filtration rate is 40 mL/minute. 4. The 24-hour creatinine clearance is 100 mL/minute.
3. The glomerular filtration rate is 40 mL/minute.
Which intervention would be the most important before attempting to catheterize a client? 1. Determine the client's history of catheter use. 2. Evaluate the level of anxiety of the client. 3. Verify that the client is not allergic to latex. 4. Assess the client's sensation level and ability to void.
3. Verify that the client is not allergic to latex.
The client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client? 1. Establish a set voiding frequency of every two (2) hours while awake. 2. Encourage a family member to check every two (2) hours and assist the client to void. 3. Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency. 4. Discuss the use of a "bladder drill," including a timed voiding schedule.
4. Discuss the use of a "bladder drill," including a timed voiding schedule.
Which action should the nurse in the emergency department anticipate for a young adult patient who has had several episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach the adverse effects of acetaminophen (Tylenol).
ANS: A Obtain a stool specimen for culture. Patients with bloody diarrhea should have a stool culture for Escherichia coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea.
Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause you pain." d. "You should avoid eating any raw fruits and vegetables."
ANS: B "Avoid foods that cause pain after you eat them." The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.
Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the excess gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."
ANS: B "Ranitidine decreases gastric acid secretion." Ranitidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response "Ranitidine absorbs the gastric acid" describes the effect of antacids. The response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).
A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.
ANS: B Check the vital signs. The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.
A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient? a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) b. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix)
ANS: C Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.
An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Aluminum hydroxide c. Omeprazole (Prilosec) d. Metoclopramide (Reglan)
ANS: D Metoclopramide (Reglan) Metoclopramide can cause central nervous system side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton pump inhibitors, mucosal protectants, or antacids.
The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.
ANS: D proton pump inhibitors. Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.
A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of saturated fat in the diet. b. a family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs).
ANS: D use of nonsteroidal antiinflammatory drugs (NSAIDs). Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.
A 20-year old patient with a history of Crohn's disease comes to the clinic with persistent diarrhea. What are characteristics of Crohn's disease (select all that apply)? a. Weight loss b. Rectal bleeding c. Abdominal pain d. Toxic megacolon e. Has segmented distribution f. Involves the entire thickness of the bowel wall
a, c, e, f. Crohn's disease may have severe weight loss, segmented distribution through the entire wall of the bowel, and crampy abdominal pain. Rectal bleeding and toxic megacolon are more often seen with ulcerative colitis.
Which patient is at highest risk for having a gastric ulcer? a. 55-year-old female, smoker, with nausea and vomiting b. 45-year-old female admitted for illicit drug detoxification c. 37-year-old male, smoker, who fell while looking for a job d. 27-year-old male who is being divorced and has back pain
a. 55-year-old female, smoker, with nausea and vomiting The 55-year-old female smoker experiencing nausea and vomiting is more likely to have a gastric ulcer. The other patients are not in the highest-risk age range or do not have enough risk factors. Although lower socioeconomic status, smoking, and drug use do increase the risk of gastric ulcers, these patients are more likely to experience duodenal ulcers but further assessment is needed.
Regardless of the precipitating factor, what causes the injury to mucosal cells in peptic ulcers? a. Acid back diffusion into the mucosa b. The release of histamine from GI cells c. Ammonia formation in the mucosal wall d. Breakdown of the gastric mucosal barrier
a. Acid back diffusion into the mucosa The ultimate damage to the tissues of the stomach and duodenum, precipitating ulceration, is acid back diffusion into the mucosa. The gastric mucosal barrier is protective of the mucosa but without the acid environment and damage, ulceration does not occur. Ammonia formation by H. pylori and release of histamine impair the barrier but are not directly responsible for tissue injury.
A postoperative patient has a nursing diagnosis of pain related to effects of medication and decreased GI motility as evidenced by abdominal pain and distention and inability to pass flatus. Which nursing intervention is most appropriate for this patient? a. Ambulate the patient more frequently. b. Assess the abdomen for bowel sounds. c. Place the patient in high Fowler's position. d. Withhold opioids because they decrease bowel motility.
a. Ambulate the patient more frequently. a. The abdominal pain and distention that occur from the decreased motility of the bowel should be treated with increased ambulation and frequent position changes to increase peristalsis. If the pain is severe, cholinergic drugs, rectal tubes, or application of heat to the abdomen may be prescribed. Assessment of bowel sounds is not an intervention to relieve the pain and a high Fowler's position is not indicated. Opioids may still be necessary for pain control and motility can be increased by other means.
A patient with ulcerative colitis has a total proctocolectomy with formation of a terminal ileumstoma. What is the most important nursing intervention for this patient postoperatively? a. Measure the ileostomy output to determine the status of the patient's fluid balance. b. Change the ileostomy appliance every 3 to 4 hours to prevent leakage of drainage onto the skin. c. Emphasize that the ostomy is temporary and the ileum will be reconnected when the large bowel heals. d. Teach the patient about the high-fiber, low-carbohydrate diet required to maintain normal ileostomy drainage.
a. Measure the ileostomy output to determine the status of the patient's fluid balance. a. Initial output from a newly formed ileostomy may be as high as 1500 to 2000 mL daily and intake and output must be accurately monitored for fluid and electrolyte imbalance.
A patient is admitted to the emergency department with acute abdominal pain. What nursing intervention should the nurse implement first? a. Measurement of vital signs b. Administration of prescribed analgesics c. Assessment of the onset, location, intensity, duration, and character of the pain d. Physical assessment of the abdomen for distention, bowel sounds, and pigmentation changes
a. Measurement of vital signs The patient with an acute abdomen may have significant fluid or blood loss into the abdomen and evaluation of blood pressure (BP) and heart rate (HR) should be the first intervention, followed by assessment of the abdomen and the nature of the pain. Analgesics should be used cautiously until a diagnosis can be determined so that symptoms are not masked.
What type of bleeding will a patient with peptic ulcer disease with a slow upper GI source of bleeding have? a. Melena c. Coffee-ground emesis b. Occult blood d. Profuse bright-red hematemesis
a. Melena Melena is black, tarry stools from slow bleeding from an upper GI source when blood passes through the GI tract and is digested. Occult blood is the presence of guaiac-positive stools or gastric aspirate. Coffee-ground emesis is blood that has been in the stomach for some time and has reacted with gastric secretions. Profuse bright-red hematemesis is arterial blood that has not been in contact with gastric secretions, as in esophageal or oral bleeding.
An 82-year-old man is admitted with an acute attack of diverticulitis. What should the nurse include in his care? a. Monitor for signs of peritonitis. b. Treat with daily medicated enemas. c. Prepare for surgery to resect the involved colon. d. Provide a heating pad to apply to the left lower quadrant.
a. Monitor for signs of peritonitis. The inflammation and infection of diverticula cause small perforations with spread of the inflammation to the surrounding area in the intestines.
Malnutrition can be a big problem for patients with cirrhosis. Which nursing intervention can help to improve nutrient intake? a. Oral hygiene before meals and snacks c. Improve oral intake by feeding the patient b. Provide all foods the patient likes to eat d. Limit snack offers to when the patient is hunger
a. Oral hygiene before meals and snacks
The client with chronic pyelonephritis is being admitted to a medical unit for intensive intravenous therapy. Which assessment data support the diagnosis of chronic pyelonephritis? a. The client has fever, chills, flank pain, and dysuria. b. The client complains of fatigue, headaches, and increased urination. c. The client had a group b beta hemolytic strep infection last week.4. The client has an acute viral pneumonia infection.
a. The client has fever, chills, flank pain, and dysuria.
The patient being treated with diuretics for ascites from cirrhosis must be monitored for (select all that apply)? a. GI bleeding d. Body image disturbances b. Hypokalemia e. Increased clotting tendencies c. Renal function
b, c. With diuretic therapy, fluid and electrolyte balance must be monitored; serum levels of sodium, potassium, chloride, and bicarbonate must be monitored, especially hypokalemia. Renal function must be monitored with blood urea nitrogen and serum creatinine. Water excess is manifested by muscle cramping, weakness, lethargy, and confusion. GI bleeding, body image disturbances, and bleeding tendencies seen with cirrhosis are not related to diuretic therapy.
Which esophageal disorder is described as a precancerous lesion associated with GERD? a. Achalasia b. Barrett's esophagus c. Esophageal strictures d. Esophageal diverticula
b. Barrett's esophagus Barrett's esophagus is an esophageal metaplasia primarily related to gastroesophageal reflux disease(GERD). Achalasia is a rare chronic disorder with the absence of peristalsis of the lower two thirds of the esophagus. Esophageal strictures are narrowing of the esophagus from scarring by many causes. Esophageal diverticula are saclike outpouchings of one or more layers of the esophagus commonly seen above the esophageal sphincter.
A large number of children at a public school have developed profuse diarrhea and bloody stools. The school nurse suspects food poisoning related to food from the school cafeteria and requests analysis and culture of which food? a. Chicken b. Ground beef c. Commercially canned fish d. Salads with mayonnaise dressing
b. Ground beef Food poisoning caused by Escherichia coli is characterized by profuse diarrhea, abdominal cramping, and bloody stools and is most often associated with contaminated beef, especially ground beef. Salmonella contamination most often occurs with poultry, staphylococcal infections occur with milk and salad dressings, and botulism occurs with fish and low-acid canned products.
Combined with clinical manifestations, what is the laboratory finding that is most commonly used to diagnose acute pancreatitis? a. Increased serum calcium c. Increased urinary amylase b. Increased serum amylase d. Decreased serum glucose
b. Increased serum amylase Although serum lipase levels and urinary amylase levels are increased, an increased serum amylase level is the criterion most commonly used to diagnose acute pancreatitis in the first 24 to 72 hours. Serum calcium levels are decreased.
What laboratory test results should the nurse expect to find in a patient with cirrhosis? a. Serum albumin: 7.0 g/dL (70 g/L) b. Total bilirubin: 3.2 mg/dL (54.7 mmol/L) c. Serum cholesterol: 260 mg/dL (6.7 mmol/L) d. Aspartate aminotransferase (AST): 6.0 U/L (0.1 mkat/L)
b. Total bilirubin: 3.2 mg/dL (54.7 mmol/L) Serum bilirubin, both direct and indirect, would be expected to be increased in cirrhosis. Serum albumin and cholesterol are decreased and liver enzymes, such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT), are initially elevated but may be normal in end-stage liver disease.
Nursing management of the patient with chronic gastritis includes teaching the patient to a. take antacids before meals to decrease stomach acidity. b. maintain a nonirritating diet with six small meals a day. c. eliminate alcohol and caffeine from the diet when symptoms occur. d. use nonsteroidal anti-inflammatory drugs (NSAIDs) instead of aspirin for minor pain relief.
b. maintain a nonirritating diet with six small meals a day. A nonirritating diet with six small meals a day is recommended to help control the symptoms of gastritis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often as irritating to the stomach as aspirin and should not be used in the patient with gastritis. Antacids are often used for control of symptoms but have the best neutralizing effect if taken after meals. Alcohol and caffeine should be eliminated entirely because they may precipitate gastritis.
The nurse determines that teaching for the patient with peptic ulcer disease has been effective when the patient makes which statement? a. "I should stop all my medications if I develop any side effects. "b. "I should continue my treatment regimen as long as I have pain. "c. "I have learned some relaxation strategies that decrease my stress. "d. "I can buy whatever antacids are on sale because they all have the same effect."
c. "I have learned some relaxation strategies that decrease my stress. Increased vagal stimulation from emotional stress causes hypersecretion of hydrochloric acid and stress reduction is an important part of the patient's management of peptic ulcers, especially duodenal ulcers. If side effects to medications develop, the patient should notify the healthcare provider before altering the drug regimen. Although effective treatment will promote pain relief in several days, the treatment regimen should be continued until there is evidence that the ulcer has healed completely. Interchanging brands and preparations of antacids and histamine (H2)-receptor blockers without checking with health care providers may cause harmful side effects and patients should take only prescribed medications.
The nurse identifies a need for additional teaching when a patient with acute infectious diarrhea makes whichstatement? a. "I can use A&D ointment or Vaseline jelly around the anal area to protect my skin." b. "Gatorade is a good liquid to drink because it replaces the fluid and salts I have lost." c. "I may use over-the-counter Imodium or Parepectolin when I need to control the diarrhea." d. "I must wash my hands after every bowel movement to prevent spreading the diarrhea to my family."
c. "I may use over-the-counter Imodium or Parepectolin when I need to control the diarrhea." c. Antiperistaltic agents, such as loperamide (Imodium)and paregoric, should not be used in infectious diarrhea because of the potential of prolonging exposure to the infectious agent. Demulcent agents may be used to coat and protect mucous membranes in these cases. The other options are all appropriate measures to use in cases of infectious diarrhea.
The nurse determines that further discharge instruction is needed when the patient with acute pancreatitis makes which statement? a. "I should observe for fat in my stools." b. "I must not use alcohol to prevent future attacks of pancreatitis." c. "I shouldn't eat any salty foods or foods with high amounts of sodium." d. "I will need to continue to monitor my blood glucose levels until my pancreas is healed."
c. "I shouldn't eat any salty foods or foods with high amounts of sodium."
The patient is receiving the following medications. Which one is prescribed to relieve symptoms rather than treat a disease? a. Corticosteroids b. 6-Mercaptopurine c. Antidiarrheal agents d. Sulfasalazine (Azulfidine)
c. Antidiarrheal agents Antidiarrheal agents only relieve symptoms. Corticosteroids, 6-mercaptopurine, and sulfasalazine(Azulfidine) are used to treat and control inflammation with various diseases.
What laboratory findings are expected in ulcerative colitis as a result of diarrhea and vomiting? a. Increased albumin b. Elevated white blood cells (WBCs) c. Decreased Na+, K+, Mg+, Cl-, and HCO3- d. Decreased hemoglobin (Hgb) and hematocrit (Hct)
c. Decreased Na+, K+, Mg+, Cl-, and HCO3- In the patient with ulcerative colitis, decreased Na+, K+,Mg+, Cl-, and HCO3- are a result of diarrhea and vomiting. Hypoalbuminemia may be present. Elevated WBCs occur with toxic megacolon. Decreased hemoglobin (Hgb) and hematocrit (Hct) occur with bloody diarrhea.
Which manifestations may be seen in the patient with cirrhosis related to esophageal varices? a. Jaundice, peripheral edema, and ascites from increased intrahepatic pressure and dysfunction b. Loss of the small bile ducts and cholestasis and cirrhosis in patients with other autoimmune disorders c. Development of collateral channels of circulation in inelastic, fragile esophageal veins as a result of portal hypertension d. Scarring and nodular changes in the liver lead to compression of the veins and sinusoids, causing resistance of blood flow through the liver from the portal vein
c. Development of collateral channels of circulation in inelastic, fragile esophageal veins as a result of portal hypertension
What does the nurse include when teaching a patient with newly diagnosed peptic ulcer disease? a. Maintain a bland, soft, low-residue diet. b. Use alcohol and caffeine in moderation and always with food. c. Eat as normally as possible, eliminating foods that cause pain or discomfort. d. Avoid milk and milk products because they stimulate gastric acid production.
c. Eat as normally as possible, eliminating foods that cause pain or discomfort. There is no specific diet used for the treatment of peptic ulcers and patients are encouraged to eat as normally as possible, eliminating foods that cause discomfort or pain. Eating six meals a day prevents the stomach from being totally empty and is also recommended. Caffeine and alcohol should be eliminated from the diet because they are known to cause gastric irritation. Milk and milk products do not need to be avoided but they can add fat content to the diet.
What should the nurse teach the patient with diverticulosis to do? a. Use anticholinergic drugs routinely to prevent bowel spasm. b. Have an annual colonoscopy to detect malignant changes in the lesions. c. Maintain a high-fiber diet and use bulk laxatives to increase fecal volume. d. Exclude whole grain breads and cereals from the diet to prevent irritating the bowel.
c. Maintain a high-fiber diet and use bulk laxatives to increase fecal volume. Formation of diverticula is common when decreased bulk of stool, combined with a more narrowed lumen in the sigmoid colon, causes high intraluminal pressures that result in saccular dilation or outpouching of the mucosa through the muscle of the intestinal wall.
During the treatment of the patient with bleeding esophageal varices, what is the most important thing the nurse should do? a. Prepare the patient for immediate portal shunting surgery. b. Perform guaiac testing on all stools to detect occult blood. c. Maintain the patient's airway and prevent aspiration of blood. d. Monitor for the cardiac effects of IV vasopressin and nitroglycerin.
c. Maintain the patient's airway and prevent aspiration of blood.
How should the nurse teach the patient with a hiatal hernia or GERD to control symptoms? a. Drink 10 to 12 oz of water with each meal. b. Space six small meals a day between breakfast and bedtime. c. Sleep with the head of the bed elevated on 4- to 6-inch blocks d. Perform daily exercises of toe-touching, sit-ups, and weight lifting.
c. Sleep with the head of the bed elevated on 4- to 6-inch blocks The use of blocks to elevate the head of the bed facilitates gastric emptying by gravity and is strongly recommended to prevent nighttime reflux. Liquids should be taken between meals to prevent gastric distention with meals. Small meals should be eaten frequently but patients should not eat at bedtime or lie down for 2 to 3 hours after eating. Activities that involve increasing intraabdominal pressure, such as bending over, lifting, or wearing tight clothing, should be avoided.
A patient with a history of peptic ulcer disease is hospitalized with symptoms of a perforation. During the initial assessment, what should the nurse expect the patient to report? a. Vomiting of bright-red blood b. Projectile vomiting of undigested food c. Sudden, severe upper abdominal pain and back pain d. Hyperactive stomach sounds and upper abdominal swelling
c. Sudden, severe upper abdominal pain and back pain Perforation of an ulcer causes sudden, severe abdominal pain that is often referred to the back, accompanied by a rigid, board like abdomen and other signs of peritonitis. Vomiting of blood indicates hemorrhage of an ulcer and gastric outlet obstruction is characterized by projectile vomiting of undigested food, hyperactive stomach sounds, and upper abdominal swelling.
The nurse is preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which would be a long-term goal? a. The client will have a blood pressure within normal limits. b. The client will show no protein in the urine. c. The client will maintain renal function. d. The client will have clear lung sounds.
c. The client will maintain renal function.
The client diagnosed with end-stage renal disease (ESRD) is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? a. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. b. A shortened life span of red blood cells because of damage secondary to dialysis treatments. This, in turn, leads to metabolic acidosis. c. The kidney cannot excrete increased levels of acid because the kidneys cannot excrete ammonia or cannot reabsorb sodium bicarbonate. d. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.
c. The kidney cannot excrete increased levels of acid because the kidneys cannot excrete ammonia or cannot reabsorb sodium bicarbonate.
What is the most important thing the nurse should do when caring for a patient who has contracted Clostridium difficile? a. Clean the entire room with ammonia. b. Feed the patient yogurt with probiotics. c. Wear gloves and wash hands with soap and water. d. Teach the family to use alcohol-based hand cleaners.
c. Wear gloves and wash hands with soap and water. Wearing gloves will avoid hand contamination and washing hands with soap and water will remove more Clostridium difficile spores than alcohol-based hand cleaners and ammonia-based disinfectants. The entire room will need to be disinfected with a 10% solution of household bleach. Probiotics may help to prevent diarrhea in the patient on antibiotics by replacing normal intestinal bacteria.
When caring for a patient with an acute exacerbation of a peptic ulcer, the nurse finds the patient doubled up in bed with shallow, grunting respirations. Which action should the nurse take first? a. Irrigate the patient's NG tube. b. Notify the health care provider. c. Place the patient in high-Fowler's position. d. Assess the patient's abdomen and vital signs.
d. Assess the patient's abdomen and vital signs. Abdominal pain that causes the knees to be drawn up and shallow, grunting respirations in a patient with peptic ulcer disease are characteristic of perforation and the nurse should assess the patient's vital signs and abdomen before notifying the health care provider. Irrigation of the NG tube should not be performed because the additional fluid maybe spilled into the peritoneal cavity and the patient should be placed in a position of comfort, usually on the side with the head slightly elevated.
What extraintestinal manifestations are seen in both ulcerative colitis and Crohn's disease? a. Celiac disease and gallstones b. Peptic ulcer disease and uveitis c. Conjunctivitis and colonic dilation d. Erythema nodosum and osteoporosis
d. Erythema nodosum and osteoporosis Ulcerative colitis and Crohn's disease have many of the same extraintestinal symptoms, including erythema nodosum and osteoporosis, as well as gallstones, uveitis, and conjunctivitis. Colonic dilation and celiac disease are not extraintestinal.
Which complication of acute pancreatitis requires prompt surgical drainage to prevent sepsis? a. Tetany c. Pleural effusion b. Pseudocyst d. Pancreatic abscess
d. Pancreatic abscess A pancreatic abscess is a collection of pus that must be drained to prevent infection of adjacent organs and sepsis. Tetany from hypocalcemia is treated with IV calcium gluconate (10%). Although pseudocysts usually resolve spontaneously, they may be treated with surgical, percutaneous catheter, or endoscopic drainage to prevent perforation. Pleural effusion is treated by treating the cause(pancreatitis) and monitoring for respiratory distress and oxygen saturation.
. The patient presents with jaundice and itching, steatorrhea, and liver enlargement. This patient has also had ulcerative colitis for several years. What diagnosis should the nurse expect for this patient? a. Cirrhosis c. Hepatorenal syndrome b. Acute liver failure d. Primary sclerosing cholangitis
d. Primary sclerosing cholangitis
The nurse is teaching the patient and family that peptic ulcers are a. Caused by a stressful lifestyle and other acid-producing factors such as H. Pylori b. Inherited within families and reinforced by bacterial spread of Staphylococcus aureus in childhood c. Promoted by factors that tend to cause oversecretion of acid, such as excess dietary fats, smoking, and H. Pylori d. Promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol
d. Promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol
What is the rationale for treating acute exacerbation of peptic ulcer disease with NG intubation? a. Stop spillage of GI contents into the peritoneal cavity b. Remove excess fluids and undigested food from the stomach c. Feed the patient the nutrients missing from the lack of ingestion d. Remove stimulation for hydrochloric acid and pepsin secretion by keeping the stomach empty
d. Remove stimulation for hydrochloric acid and pepsin secretion by keeping the stomach empty NG intubation is used with acute exacerbation of peptic ulcer disease to remove the stimulation for hydrochloric acid (HCl) and pepsin secretion by keeping the stomach empty. Stopping the spillage of GI contents into the peritoneal cavity is used for peritonitis. Removing excess fluids and undigested food from the stomach is the rationale for using NG intubation for gastric outlet obstruction.
The occurrence of acute liver failure is most common in which situation? a. An individual with hepatitis A b. An individual with hepatitis C c. Antihypertensive medication use d. Use of acetaminophen with alcohol abuse
d. Use of acetaminophen with alcohol abuse The most common cause of acute liver failure is drugs, usually acetaminophen in combination with alcohol abuse. HBV is the second most common cause.
When assessing a patient with acute pancreatitis, the nurse would expect to find a. hyperactive bowel sounds. c. a temperature greater than 102°F (38.9°C). b. hypertension and tachycardia. d. severe midepigastric or left upper quadrant (LUQ) pain.
d. severe midepigastric or left upper quadrant (LUQ) pain.
