Saunders Comprehensive Review
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1."I should increase the fiber in my diet." 2."I will need to avoid caffeinated beverages." 3."I'm going to learn some stress reduction techniques." 4."I can have exacerbations and remissions with Crohn's disease."
"I should increase the fiber in my diet." Rationale: Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1."I should increase the fiber in my diet." 2."I will need to avoid caffeinated beverages." 3."I'm going to learn some stress reduction techniques." 4."I can have exacerbations and remissions with Crohn's disease."
"I should increase the fiber in my diet." Rationale:Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.
Dicyclomine hydrochloride has been prescribed for a client with irritable bowel syndrome, and the nurse provides instructions to the client about how to take this medication. Which statement, if made by the client, indicates an understanding of how to take this medication? "I should take the pill with food and at mealtimes." 2."I should take the pill 30 minutes before each meal." 3."I should take the pill after I have finished eating my meal." 4."I should take the pill when I first wake up in the morning and right before I go to bed."
"I should take the pill 30 minutes before each meal." Rationale: Dicyclomine hydrochloride is an anticholinergic, antispasmodic agent often used to treat irritable bowel syndrome that is unresponsive to diet therapy. To be effective in decreasing bowel motility, antispasmodic medication should be administered 30 minutes before meals. The other options are incorrect.
The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? 1."The pain doesn't usually come right after I eat." 2."The pain gets so bad that it wakes me up at night." 3."The pain that I get is located on the right side of my chest." 4."My pain comes shortly after I eat, maybe a half hour or so later."
"My pain comes shortly after I eat, maybe a half hour or so later." Rationale: Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.
The nurse has given instructions to a client who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instruction? 1."I will continue taking vitamin supplements." 2."This medication will help lower my cholesterol." 3."This medication should only be taken with water." 4."A high-fiber diet is important while taking this medication."
"This medication should only be taken with water." Rationale: Cholestyramine is a bile acid sequestrant used to lower the cholesterol level, and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption.
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply 1.Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 3.Give small, frequent high-calorie feedings. 4.Maintain the client in a supine and flat position. 5.Give hydromorphone intravenously as prescribed for pain. 6.Maintain intravenous fluids at 10 mL/hr to keep the vein open
1, 2, 5 Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.
A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply 1.Orthopnea and dyspnea 2.Petechiae and ecchymosis 3.Inguinal or umbilical hernia 4.Poor body posture and balance 5.Abdominal distention and tenderness
1,2,3,5 Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.
The nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply. 1.Leukopenia 2.Elevated hemoglobin 3.Elevated liver enzymes 4.Elevated serum bilirubin level 5.Elevated blood urea nitrogen (BUN) 6.Elevated serum erythrocyte sedimentation rate (ESR)
1,3,4,6 Rationale: Laboratory indicators of hepatitis include leukopenia, elevated liver enzyme levels, elevated serum bilirubin levels, and elevated ESRs. An elevated BUN level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.
The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. 1.U waves 2.Widened T wave 3.Prominent U wave 4.Prolonged QT interval 5.Prolonged ST segment
4, 5 Rationale: A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.
The adult client with hepatic encephalopathy has a serum ammonia level of 200 mcg/dL (120 mcmol/L) and receives treatment with lactulose. The nurse determines that the client had the best and most realistic response if the serum ammonia level changed to which value after medication administration? 1.5 mcg/dL (3 mcmol/L) 2.10 mcg/dL (6 mcmol/L) 3.15 mcg/dL (9 mcmol/L) 4.90 mcg/dL (54 mcmol/L)
90 mcg/dL (54 mcmol/L) Rationale: The normal serum ammonia level is 10 to 80 mcg/dL (6 to 47 mcmol/L). In the client with hepatic encephalopathy, the ammonia level is not likely to drop below normal, nor is it likely to drop into the low-normal range. A level of 90 mcg/dL (54 mcmol/L) is slightly above normal and represents the most realistic response of the medication. The nurse should also monitor the client for signs and symptoms that indicate improvement in the condition.
The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client? 1.A pale color 2.A purple color 3.A brick-red color 4.A large amount of red drainage
A brick-red color Rationale: Normal characteristics of a stoma include a rose to brick-red color indicating viable mucosa, mild to moderate edema during the initial postoperative period, and a small amount of oozing blood from the stoma mucosa (because of its high vascularity) when it is touched. A pale color may indicate anemia. A stoma that is dark red to purple indicates inadequate blood supply to the stoma or bowel due to adhesions, low blood flow state, or excessive tension on the bowel at the time of construction. A small amount of bleeding is considered normal, but a moderate to large amount of bleeding from the stoma mucosa could indicate coagulation factor deficiency, stomal varices secondary to portal hypertension, or lower gastrointestinal bleeding.
A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the primary health care provider for which type of diet for this client?
A low-fiber diet Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be added gradually to the diet
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1.Bradycardia 2.Numbness in the legs 3.Nausea and vomiting 4.A rigid, board-like abdomen
A rigid, board-like abdomen Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.
The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session? 1.The diet should be low in calories. 2.Meals should be large to conserve energy. 3.Activity should be limited to prevent fatigue. 4.Alcohol intake should be limited to 2 ounces per day.
Activity should be limited to prevent fatigue. Rationale: Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1.A decreased pH and an increased Paco2 2.An increased pH and a decreased Paco2 3.A decreased pH and a decreased HCO3- 4.An increased pH and an increased HCO3-
An increased pH and an increased HCO3- Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.
A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? 1.Call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction.
Check the suction device to make sure it is working. Rationale: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.
The nurse is reviewing the laboratory test results for a client and notes that the albumin level is 3.0 g/dL (30 g/L). The nurse understands that this laboratory value would be noted in which condition?
Cirrhosis of the liver RationaleThe normal albumin level ranges from 3.5 to 5 g/dL (35 to 50 g/L). The albumin level is decreased in many conditions, such as acute infection, ascites, alcoholism, burns, and cirrhosis. The remaining options identify conditions in which the albumin level is increased.
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? 1.Notify the surgeon. 2.Measure abdominal girth. 3.Irrigate the nasogastric tube. 4.Continue to monitor the drainage.
Continue to monitor the drainage. Rationale: Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the surgeon at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific surgeon prescriptions to do so.
Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? 1.Decreased diarrhea 2.Decreased cramping 3.Improved intestinal tone 4.Elimination of peristalsis
Decreased diarrhea Rationale: Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication.
The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client? 1. Deficient fluid volume related to acute blood loss 2. Risk for aspiration related to acute bleeding in the GI tract 3. Risk for infection related to acute disease process and medications 4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased metabolism
Deficient fluid volume related to acute blood loss Rationale: The priority problem for the client with acute gastrointestinal bleeding among these options is deficient fluid volume related to acute blood less. This state can result in decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration and infection, but these are not actual problems at this point in time.
The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase?
Fatigue, anorexia, and nause Rationale:In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1.Folate deficiency 2.Malabsorption of fat 3.Intestinal obstruction 4.Fluid and electrolyte imbalance
Fluid and electrolyte imbalance Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1.Diarrhea 2.Heartburn 3.Flatulence 4.Constipation
Heart Burn Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.
A client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. Which finding indicates that the client is experiencing optimal effects of the medication? 1.Heartburn is relieved. 2.Muscle twitching stops. 3.The serum calcium level increases. 4.The serum phosphorus level decreases.
Heartburn is relieved Rationale: Calcium carbonate can be used as an antacid for the relief of heartburn and indigestion. Calcium carbonate also can be used as a calcium supplement (serum calcium level increases) or to bind phosphorus in the gastrointestinal tract with chronic kidney disease (serum phosphorus level decreases). Although adequate calcium levels are needed for proper neurological function, a reduction in muscle twitching is not an expected outcome when taking the medication for duodenal ulcer.
To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test should the nurse assess? 1.Hepatitis B virus DNA 2.Prolonged prothrombin time 3.Hepatitis B surface antigen (HBsAg) 4.Antibody to surface antigen (anti-HBs)
Hepatitis B surface antigen (HBsAg) Rationale: HBsAg is present in chronic carriers. Hepatitis B virus DNA indicates viral replication. A prolonged prothrombin time is caused by decreased absorption of vitamin K in the intestine with decreased production of prothrombin by the liver. Anti-HBs is a marker for the response to the vaccine and indicates immunity to hepatitis B.
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1.Ambulate following a meal. 2.Eat high-carbohydrate foods. 3.Limit the fluids taken with meals. 4.Sit in a high-Fowler's position during meals.
Limit the fluids taken with meals. Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.
The nurse is caring for a client who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse should anticipate a primary health care provider prescription for which type of suction? 1.High and intermittent 2.Low and intermittent 3.High and continuous 4.Low and continuous
Low and intermittent Rationale: Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.
The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1.Modified left lateral recumbent position 2.Modified right lateral recumbent position 3.On the left side of the body, with the head of the bed elevated 45 degrees 4.On the right side of the body, with the head of the bed elevated 45 degrees
Modified left lateral recumbent position Rationale: For administering an enema, the client is placed in a modified left lateral recumbent position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm
Pain relieved by food intake Rationale:A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? 1.Evaluating for asterixis 2.Inspecting for petechiae 3.Palpating for peripheral edema 4.Evaluating for decreased level of consciousness
Palpating for peripheral edema Rationale: Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1.Sweating and pallor 2.Bradycardia and indigestion 3.Double vision and chest pain 4.Abdominal cramping and pain
Sweating and pallor Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
A client with a history of gastroesophageal reflux disease (GERD) is diagnosed with peptic ulcer disease (PUD). The primary health care provider prescribes sucralfate in addition to the client's other medications. What teaching should the nurse include in this client's instructions? 1.Take the sucralfate once a day at bedtime with food. 2.Take the sucralfate daily with the proton pump inhibitor. 3.Take the sucralfate before meals and at bedtime on an empty stomach. 4.Take the sucralfate immediately after eating and within 30 minutes of an antacid.
Take the sucralfate daily with the proton pump inhibitor. Rationale: Sucralfate is an antiulcer medication that promotes ulcer healing by creating a protective barrier against acid and pepsin. It should be taken on an empty stomach. The usual recommended adult dosage is 1 gram 4 times a day, taken 1 hour before meals and at bedtime. Options 1, 2, and 4 are incorrect, as sucralfate should be taken on an empty stomach, at least twice a day, and at least 30 minutes apart from an antacid.
The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? 1.Recently retired from a job 2.Significant other has a gastric ulcer 3.Occasionally drinks 1 cup of coffee in the morning 4.Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis
Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis Rationale: Risk factors for PUD include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, NSAIDs, caffeine, alcohol, and stress. When an NSAID is taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn's disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for PUD by changing the amount of gastric and biliary acids produced. Recent retirement should decrease stress levels rather than increase them. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. A significant other is not a first-degree relative; therefore, no genetic connection is noted in this relationship. Although caffeinated drinks are a known risk factor for PUD, the option states that the client drinks 1 cup of coffee occasionally.
The nurse is caring for a client admitted to the hospital with suspected acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1.White blood cell (WBC) count of 4000 mm3 (4 × 109/L) 2.WBC count of 8000 mm3 (8 × 109/L) 3.WBC count of 18,000 mm3 (18 × 109/L) 4.WBC count of 26,000 mm3 (26 × 109/L)
WBC count of 18,000 mm3 (18 × 109/L) Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the WBC count (leukocytosis) to 10,000 to 18,000 mm3 (10 to 18 × 109/L) with an increased number of immature WBCs. An inflammatory process causes a rise in the WBC count. A rise to 26,000 mm3 (26 × 109/L) may indicate a perforated appendix (greater than 20,000 mm3 [20 × 109/L]).