questions for exam 3 232

A patient has been admitted to the hospital with GI bleeding. Which is a prioritynursing action for this patient? A. Obtain complete vital signs. B. Administer prescribed medication for pain. C. Administer prescribed antacids every 2 hours. D. Administer prescribed medication for nausea and vomiting

A, GI bleeding = hypotensive shock = monitor vital signs!!

A palliative care nurse understands that nurses can employ various interventions to help clients with their grief. An example of an independent intervention which can be utilized is: A. Requesting a referral to group therapy, bereavement groups, and grief therapists B. Requesting a referral to a social worker who can provide expert guidance about coping with loss C. Facilitating meetings between the hospital chaplain and the client D. Using active listening techniques to show full engagement in the interaction

D, ***An independent intervention for clients with alterations in grief include using active listening techniques to show full engagement in interaction. All other interventions are important, however, are collaborative in nature rather than independent.

The nurse is caring for an older adult patient who reports continued problems with constipation. What intervention can be implemented to promote timely bowel movements? A. Increase fiber intake B. Limit fluid intake to 1500 mL daily C. Administration of an oil retention enema weekly D. Take a mild over-the-counter laxative each evening

A

A client is admitted to the hospital with the diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client? A. controlling constipation B. Meeting nutritional needs C. Preventing increase weakness D. Anticipating a sexual alteration

B. To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high calorie, high protein diet is advised. Diarrhea, not constipation is a problem with Crohn disease. Preventing an increase and weakness is a secondary concern that results from malnutrition. Correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.

After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective? A. "I can have a glass of low-fat milk at bedtime." B. "I will have to eliminate all spicy foods from my diet." C. "I will have to use herbal teas instead of caffeinated drinks." D. "I should keep something in my stomach all the time to neutralize the excess acids."

C, Rationale: Patients with gastroesophageal reflux disease should avoid foods (such as tea and coffee) that decrease lower esophageal pressure. Patients should also avoid milk, especially at bedtime, as it increases gastric acid secretion. Patients may eat spicy foods, unless these foods cause reflux. Small, frequent meals help prevent overdistention of the stomach, but patients should avoid late evening meals and nocturnal snacking.

The nurse is eliciting a health history from a client with ulcerative colitis. Which factor would the nurse consider to be MOST likely associated with the clients colitis? A. Food allergy B. Infectious agent C. Dietary components D. genetic predisposition

D. Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease are familial, which suggest that they are hereditary. Although, food allergy and infectious agents may be causative factors. They are not the most common factors. No specific dietary component has been identified.

1. The nurse is reviewing the record of a client with Crohn's Disease. Which stool characteristic the nurse expects to see documented in the record? A. Diarrhea B. Constipation C. Bloody Stools D. Stool constantly oozing from rectum

Diarrhea

A client with irritable bowel syndrome has asked the nurse if there is anything that can be done to decrease the frequency of diarrhea. Which of the following advice is appropriate for a client to develop regular bowel functioning? Select all that apply a. Utilize narcotics to reduce pain b. Drink 8 to 10 glasses of liquids per day c. Eat the largest meal of the day in the evening d. Decrease activity levels and increase rest e. Increase intake of fiber

B, E

A client has a diagnosis of hemorrhoids. Which signs and symptoms would the nurse expect the client to report. Select all that apply. A. flatulence B. anal itching C. blood in stool D. rectal bulging E. pain when defecating

B, C, D, E. Anal pruritus (itching) occurs as varicosities enlarge and become inflamed. Blood and mucous in the stool occur during a bowel movement. Rectal bulging occurs as portal venous pressure increases and varicosities enlarge. Pain occurs when varicosities enlarge and thrombosis occur. Pain increases on defecation. Flatulence is unrelated to hemorrhoids.

1. When a patient experiences a severe exacerbation of Crohn disease, the priority pharmacologic treatment would be administration of which class of medication? A. Analgesics B. Antibiotics C. Antidiarrheals D. Corticosteroids

D

A client has diarrhea. What should the nurse expect when auscultating the abdomen? a. Hypoactive bowel sounds b. Absent bowel sounds c. High-pitched bowel sounds d. Hyperactive bowel sounds

D

The nurse is assessing a client with a diagnosis of hemorrhoids. Which factors in the clients history most likely played a role in the development of hemorrhoid's. Select all that apply. A. Constipation B. Hypertension C. Eating spicy foods D. Bowel incontinence E. numerous pregnancies

A, E. Straining at stool increases intra-abdominal, systemic, and portal venous pressures that promote the development of hemorrhoids. The enlarging uterus from pregnancies puts pressure on the interior vena cava that leads to increased portal venous pressure causing anorectal varicosities. Hypertension would not contribute to the development of hemorrhoids, however portal hypertension can precipitate hemorrhoids. Spicy foods may irritate hemorrhoids, but do not cause them. Bowel incontinence is unrelated to the development of hemorrhoids.

An older clients colonoscopy reveals the presence of extensive diverticulosis. Which type of diet would the nurse encourage the client to follow? A. Low-fat diet B. High-fiber diet C. High-protein diet D. Low-carbohydrate diet

B. A high-fiber diet is recommended for diverticulosis. Fiber promotes passage of residue through the intestine, thereby preventing constipation. Constipation causes straining at stool. This increases intraluminal pressure, which can precipitate diverticulitis or perforation of diverticula. Low-fat, high-protein and low-carbohydrate diets are not indicated for diverticulosis.

A nurse caring for a grieving family is aware that complicated grief may occur. A manifestation of complicated grief is: A. Not seeking support after a loss due to feelings of shame, guilt, or lack of recognition of the loss B. Hiding grief from others as opposed to allowing support from friends and family C. Intense grieving for 6 months or more with little to no indication of grief resolution D. More pronounced feelings of anger and depression due to resentment over the unacknowledged loss

C, Complicated grief is an alteration in the grieving process defined as prolonged or intensified grief causing an individual to be unable to proceed with the grieving process. A manifestation of complicated grief is intense grieving for 6 months or more with little to no indication of grief resolution. All other manifestations are for disenfranchised grief, another alteration in the grieving process.

What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? A. Take a dose of mineral oil at the same time. B. Add extra salt to food on at least one meal tray. C. Ensure dietary intake of 10 g of fiber each day. D. Take each dose with a full glass of water or other liquid.

D, Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

A client reports that they haven't had a bowel movement in three days. The nurse should promote which of the following to help the client with gastrointestinal peristalsis? Select all that apply. A. Semi-private bathroom access B. Docusate sodium C. Increased fluid intake D. Abdominal massage E. Ambulation

B, C, E

The nurse is caring for a client who has been diagnosed with appendicitis and is scheduled for surgery later today. Which of the following assessment findings is the MOST concerning? A. Sudden pain relief B. Abdominal pain at McBurney's point C. Increased WBC on CBC D. Rebound tenderness

A

When planning care for the patient with acute pancreatitis, the LPN/LVN knowswhich intervention is a priority of care? A. Pain control B. Nutritional supplementation C. Observation for mental changes D. Observation for intestinal obstruction

A

A client is experiencing an exacerbation of ulcerative colitis. A low residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? A. Reduce gastric acidity B. Reduce colonic irritation C. Reduce intestinal absorption D. Reduce bowel infection rate

B, A low residue diet is designed to reduce colonic irritation, motility and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation and motility and spasticity hopefully will increase not reduce intestinal absorption. This diet is followed to allow the bowel to rest not to reduce infection rates.

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? A. Skin condition B. Fluid and electrolyte balance C. Food intake D. Fluid intake and output

B. Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life threatening condition and it not the priority nursing intervention. Fluid intake and output provides information about fluid balance only without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.

After many years of coping with ulcerative colitis, a patient makes a decision to have a colectomy as advised by the primary healthcare provider. Which is MOST likely the significant factor that effected the clients decision? A. It is temporary until the colon heals B. Surgical treatment cures ulcerative colitis C. Ulcerative colitis can progress to Crohn disease Without surgery, eating table foods is contraindicated

B. When the diseased bowel is removed, the clients symptoms cease. Surgical removal of a body part is not temporary, but permanent. Ulcerative colitis does not progress to Crohn disease. Clients with ulcerative colitis have an increased risk for Colorectal cancer. Without surgery, eating table foods is contraindicated, is not a true statement; these clients can still eat table food.

The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? A. Morphine sulfate B. Zolpidem (Ambien) C. Ondansetron (Zofran) D. Dexamethasone (Decadron)

C

22. The nurse is comforting the adult daughter of a client who has just passed away. Whenplanning care, the nurse should include interventions based on which type of loss? A. Perceived B. Situational C. Developmental D. Anticipatory

C, Rationale: A developmental loss is one that is expected to occur throughout the course of life, such as the death of aging parents ; the nurse should provide interventions to address this type of loss. A perceived loss is one that cannot be verified by others. An anticipatory loss is one that is experienced before the loss actually occurs. A situational loss is one that is due to an external circumstance.

Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? A. Notify the physician. B. Auscultate for bowel sounds. C. Reposition the tube and check for placement. D. Remove the tube and replace it with a new one.

C, The tube may be resting against the stomach wall. The first action by the nurse (since this is intestinal surgery and not gastric surgery) is to reposition the tube and check it again for placement. The physician does not need to be notified unless the tube function cannot be restored by the nurse. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

A 72-year-old patient was admitted with epigastric pain due to a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care? A. Chest pain relieved with eating or drinking water B. Back pain 3 or 4 hours after eating a meal C. Burning epigastric pain 90 minutes after breakfast D. Rigid abdomen and vomiting following indigestion

D, A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3-4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1-2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

Peritonitis develops in a client who had surgery for a ruptured appendix. Which clinical findings related to peritonitis should the nurse expect the client to exhibit. Select all that apply. A. fever B. hyperactivity C. extreme hunger D. urinary retention E. abdominal muscle rigidity

A moderate fever is associated with inflammation of the peritoneal membrane. Muscular rigidity over the effected area is a classic sign of peritonitis. Malaise, rather than hyperactivity is often associated with peritonitis. Nausea, not hunger, is a common occurrences with peritonitis. Even though the kidneys are making the urine, the bladder often retains the urine after surgery as a complication of anesthesia, not peritonitis.

A patient with a history of peptic ulcer disease has presented to the emergency department reporting severe abdominal pain and has a rigid, board like abdomen that prompts the health care team to suspect a perforated ulcer. What intervention should the nurse anticipate? A. Providing IV fluids and inserting a nasogastric (NG) 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, *** 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.

A client with GERD receives a prescription for an H2 receptor antagonist. Which medications are within the classifications of an H2-receptor antagonist. Select all that apply. A. Nizatidine B. Ranitidine C. Famotidine D. Lansoprazole E. Metoclopramide

A, B, C. Nizatidine is a H2 receptor antagonist that reduced gastric acid secretion and provides for symptomatic improvement in GERD. Ranitidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement and GERD. Famotidine is a H2 receptor antagonist that reduced gastric acid secretion and provides for symptomatic improvement in GERD. lansoprazole is a proton pump inhibitor that inhibits gastric secretion up to 90% with one dose daily and provides for symptomatic improvement in GERD. Metoclopramide is a prokinetic agent that increases the rate of gastric emptying. It has multiple side effects and is not appropriate for long-term treatment of GERD.

The nurse is discussing colon cancer risks with a 40-year-old client. Which of the following are modifiable factors that contribute to an increased risk for colon cancer? Select all that apply. a. Smoking b. Advanced age c. An inactive lifestyle d. A diet high in alcohol consumption e. Inflammatory bowel disease

A, C, D

The nurse is providing nutrition instructions for a client who has inflammatory bowel disease of the ascending colon. Which suggestion by the nurse is appropriate? A. consume scrambled eggs and applesauce B. consume barbequed chicken and French fries C. consume fresh fruit salad with cheddar cheese D. Consume chunky peanut butter on whole wheat bread

A, Low-residue foods produce less fecal waste decreasing bowel contents and irritation. Protein promotes healing and calories provide energy. Barbeque foods are spicy. Foods high in fat can increase peristalsis. Fruits and aged sharp cheeses can be irritating to the bowel. Chunky peanut butter and whole wheat bread are high residue foods(high-fiber).

The nurse is caring for a client diagnosed with Crohn's disease. Which statement indicates more teaching is needed? A. "I am at risk for anemia and electrolyte disturbances" B. "I will deal with chronic constipation" C. "I will have periods of remission and periods of exacerbation" D. "A high-calorie, high-protein diet is best"

B

1. The nurse is reviewing the health history of an assigned patient. Which data in a patient's history might indicate a predisposition to diverticular disease? (Select all that apply.) A. Frequent laxative use B. Low dietary fiber intake C. High dietary fiber intake D. History of passing scant, small stools E. History of chronic diarrhea; vomiting

B, D

A palliative care nurse is caring for a terminally ill client and his family. The nurse understands that nursing implications for the grieving family include all except: A. Assist family members in understanding the signs of grief and acceptance of death. B. Help the dying client grieve for their own loss of life. C. Recognize complicated grief if symptoms occurs up to 2 months after a loss. D. Provide referral to assistance such as support groups and spiritual resources.

C, Grief is an important consideration when working with end-of-life clients. Not only are these clients learning how to come to terms with the loss of their own lives, but their families experience a variety of hardships during this time. Nursing implications for the grieving family include: helping the dying client grieve for their own loss of life; assisting family members in understanding the signs of grief and acceptance of death; and provide referral to assistance such as support groups and spiritual resources. Complicated grief is diagnosed if it occurs at 6 months after a loss. The normal process of grief begins to fade 3 to 6 months after the loss.

A client tells the nurse about recent recurrence episodes of bleeding hemorrhoids. Which instruction with the nurse provide to the client to help prevent future hemorrhoidal episodes? A. exercise to improve circulation B. eat bland foods and avoid spices C. consume high fiber diet and drink adequate water D. use laxatives to avoid constipation and use of the Valsalva maneuver

Consuming a high-fiber diet and drinking adaquate water promotes regular bowel function, prevent constipation and prevent straining which can make hemorrhoid's worse. a high-fiber diet provides bulk that stimulates peristalsis and water promotes a soft stool. Exercise is advisable but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids. Bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone and promote dependency. The Valsalva maneuver should also be avoided.

The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? A. Low-pitched and rumbling above the area of obstruction B. High-pitched and hypoactive below the area of obstruction C. Low-pitched and hyperactive below the area of obstruction D. High-pitched and hyperactive above the area of obstruction

D, Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

The nurse is teaching a client about gastrointestinal reflux disease(GERD). Which statement made by the client indicates correct understanding of GERD management? A. "Three meals per day is the best regimen to avoid GERD symptoms." B. "I can reduce my GERD symptoms through a high-carbohydrate, low-fat diet." C. "A snack at bedtime will help reduce the acidity of my stomach during the night." D. "I will place a 6 inch block(15-cm) under the head of my bed to help with digestion."

D, Elevation of the head of the bed can enhance esophageal emptying and reduce symptoms of GERD. A low-fat, high protein diet is recommended. Eating should be avoided 3 hours before bedtime to reduce acid-production and the client should be instructed to consume small, frequent meals throughout the day to avoid gastric distention.

The nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis, than in the client with Crohn disease? A. Inclusion of transmural involvement of the small bowel wall B. Higher occurrence of fistulas and absences from changes in the bowel wall C. Pathology beginning proximately with intermittent plagues found along the colon D. Involvement starting distally with rectal bleeding that spreads continuously up the colon

D. Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon. In Crohns disease, it is primarily in the terminal ilium, cecum and ascending colon. Ulcerative colitis, as the name implies, effects the colon, not the small intestine. Intermittent areas of pathology appear in Crohn. In ulcerative colitis, the pathology is in the inner layer and does not extend throughout the entire bowel wall. Therefore, abscesses and fistulas are rare, abscesses and fistulas occur more frequently in Crohn disease.

The nurse is providing discharge instructions for a client with the diagnosis of GERD. Which recommendations would the nurse give to the client to limit symptoms with GERD? Select all that apply. A. Avoid heavy lifting B. Lie down after eating C. Avoid drinking alcohol D. Eat small frequent meals E. Increase fluid intake with meals F. Wear an abdominal binder or girdle

A, C, D. Heavy lifting increases intra-abdominal pressure allowing gastric contents to move up through the lower esophageal sphincter causing heartburn. Alcohol, in addition to peppermints, caffeine and chocolate decreases lower esophageal sphincter pressure (regurgitation), which permits gastric contents to move from the stomach into the esophagus. Eating small frequent meals limits the amount of food in the stomach which limits gastroesophageal reflux. Lying down after eating promotes reflux and should be avoided. Increasing fluids with meals increases gastric volume, causing distention and reflux. Constrictive garments, such as belt, binders and girdles increase intra abdominal pressure and may lead to reflux.

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? A. Restricted to rectum B. Strictures are common. C. Bloody, diarrhea stools D. Cramping abdominal pain E. Lesions penetrate intestine.

C, D, Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

The nurse is caring for a patient with GERD. Which information would the nurse provide the client to prevent worsening of the disorder? Select all that apply. A. Eat a snack before bed B. Include vigorous exercise C. wear loose fitting clothing D. begin a weight loss program E. Sleep with head of bed elevated

C, D, E. Safety instructions to prevent the worsening of GERD include wearing loose fitting clothing, beginning a weight loss program and sleeping with the head of the bed elevated. A person with GERD should refrain from eating before bed as well as vigorous exercise.