Unit 3: Review

The client has been experiencing difficulty and straining when expelling feces. Which intervention should be taught to the client? 1. Explain that some blood in the stool will be normal for the client.' 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-fiber diet.

4.

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia? A) Warm moist skin B) Polyuria C) Bradycardia D) Hypotension

D) Hypotension Explanation: Signs of potential hypovolemia include cool, clammy skin; tachycardia; decreased blood pressure; and decreased urine output.

Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program? a. Having the adults write down the caloric intake of each meal b. Asking the adults about situations that tend to increase appetite c. Suggesting that the adults plan rewards, such as sugarless candy, for achieving their goals d. Encouraging the adults to eat small amounts frequently rather than having scheduled meals

b. Asking the adults about situations that tend to increase appetite

Which statement by the nurse is most likely to help a morbidly obese 22-year-old man in losing weight on a 1000-calorie diet? a. "It will be necessary to change lifestyle habits permanently to maintain weight loss." b. "You will decrease your risk for future health problems such as diabetes by losing weight now." c. "You are likely to notice changes in how you feel with just a few weeks of diet and exercise." d. "Most of the weight that you lose during the first weeks of dieting is water weight rather than fat."

c. "You are likely to notice changes in how you feel with just a few weeks of diet and exercise."

A nursing student is reviewing for an upcoming anatomy and physiology examination. Which of the following would the student correctly identify as a function of the liver? Select all that apply. A) Ammonia conversion B) Glucose metabolism C) Carbohydrate metabolism D) Protein metabolism E) Zinc storage

A) Ammonia conversion B) Glucose metabolism D) Protein metabolism Explanation: Functions of the liver include the metabolism of glucose, protein, fat, and drugs; conversion of ammonia; storage of vitamins and iron; formation of bile; and excretion of bilirubin. The liver is not responsible for the metabolism of carbohydrates or the storage of zinc.

The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient? A) Respiratory assessment related to increased thoracic pressure B) Peripheral vascular assessment related to immobility C) Skin assessment related to increase in bile salts D) Urinary output related to increased sodium retention

A) Respiratory assessment related to increased thoracic pressure Explanation: If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care? A) Risk for Aspiration Related to Inhalation of Gastric Contents B) Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption C) Risk for Decreased Cardiac Output Related to Vasovagal Response D) Risk for Impaired Verbal Communication Related to Oral Trauma

A. Explanation: Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the patients nutritional status and does not affect cardiac output or communication.

A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection? A) Indicates acceptance of altered appearance and demonstrates positive self-image B) Freely expresses needs and concerns related to postoperative pain management C) Compensates effectively for alteration in ability to communicate related to dysarthria D) Demonstrates effective stress management techniques to promote muscle relaxation

A. Explanation: Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the patients appearance is visibly altered. The face generally appears asymmetric, with a visible neck depression; shoulder drop also occurs frequently. These changes have the potential to negatively affect self-concept and body image. Facilitating adaptation to these changes is a crucial component of nursing intervention. Patients who have had head and neck surgery generally report less pain as compared with other postoperative patients; however, the nurse must assess each individual patients level of pain and response to analgesics. Patients may experience transient hoarseness following a radical neck dissection; however, their ability to communicate is not permanently altered. Stress management is beneficial but would not be considered the priority in this clinical situation.

Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction? a) Sudden, sustained abdominal pain b) Decreased blood pressure c) Purulent drainage from the gluteal fold d) Decreased urine output

A. Explanation: Sudden, sustained pain, abdominal distention, and fever are symptoms of perforation in a client with intestinal obstruction. A decrease in blood pressure and decrease in urine output are symptoms of shock. Purulent drainage from the gluteal fold is not a symptom of perforation; it only indicates that the client has developed a condition of anorectal abscess.

When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report? A) Black and tarry B) Clay-colored or whitish C) Yellow-green D) Blood tinged

B) Clay-colored or whitish Explanation: Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.

In what location would the nurse palpate for the liver? A) Left upper quadrant B) Right upper quadrant C) Right lower quadrant D) Left lower quadrant

B) Right upper quadrant Explanation: The liver may be palpable in the right upper quadrant. A palpable liver presents as a firm, sharp ridge with a smooth surface.

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? a) This is a normal finding 1 day after surgery. b) Blood supply to the stoma has been interrupted. c) The ostomy bag should be adjusted. d) An intestinal obstruction has occurred.

B. Explanation: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.)

A nurse in an oral surgery practice is working with a patient scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend which of the following actions? A) Rinse the mouth with alcohol before bedtime for the next 7 days. B) Use warm saline to rinse the mouth as needed. C) Brush around the area with a firm toothbrush to prevent infection. D) Use a toothpick to dislodge any debris that gets lodged in the socket.

B. Explanation: The patient should be assessed for bleeding after the tooth is extracted. The mouth can be rinsed with warm saline to keep the area clean. A firm toothbrush or toothpick could injure the tissues around the extracted area. Alcohol would injure tissues that are healing.

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is: A) Dextromethorphan B) Benadryl C) Acetaminophen D) Ibuprofen

C) Acetaminophen Although any medication can affect liver function, use of acetaminophen (found in many over-the-counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and antituberculosis agents.

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? A) Weight loss of 2 pounds in 3 days B) Anorexia for more than 3 days C) Change in the client's handwriting and/or cognitive performance D) Constipation for more than 2 days

C) Change in the client's handwriting and/or cognitive performance Explanation: The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider? A) Provide the client with nonprescription laxatives. B) Ask the client about food intake. C) Measure abdominal girth according to a set routine. D) Report the condition to the physician immediately.

C) Measure abdominal girth according to a set routine.

A patient has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient? A) Placing the patient in a left lateral position B) Administering opioids as ordered C) Placing the patient in Fowlers position D) Teaching the patient to use the patient-controlled analgesia (PCA) system

C. Explanation: After the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in Fowlers position to facilitate breathing and promote comfort. Lateral positioning does not facilitate oxygenation or comfort. Medications do not facilitate spontaneous breathing.

A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include? A) Muscle training to relieve dysphagia B) Relieving nerve paralysis in the cervical plexus C) Promoting maximum shoulder function D) Alleviating achalasia by decreasing esophageal peristalsis

C. Explanation: Shoulder drop occurs as a result of radical neck dissection. Shoulder function can be improved by rehabilitation exercises. Rehabilitation would not be initiated until the patients neck incision and graft, if present, were sufficiently healed. Nerve paralysis in the cervical plexus and other variables affecting swallowing would be managed by a speech therapist rather than a physical therapist.

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement? A) Keep the head of the bed lowered. B) Drinka cup of hot tea before bedtime. C) Avoid carbonated drinks .D) Eat a low-protein diet.

C. Explanation: For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.

A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation? A) Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash B) Applying a water-soluble gel to the teeth and gums C) Wiping the teeth and gums clean with a gauze pad D) Brushing the patients teeth with a toothbrush and small amount of toothpaste

D Explanation: Application of mechanical friction is the most effective way to cleanse the patients mouth. If the patient is unable to brush teeth, the nurse may brush them, taking precautions to prevent aspiration; or as a substitute, the nurse can achieve mechanical friction by wiping the teeth with a gauze pad. Bacteriocidal mouthwash does reduce plaque-causing bacteria; however, it is not as effective as application of mechanical friction. Water-soluble gel may be applied to lubricate dry lips, but it is not part of oral care.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? A) Portal hypertension B) Asterixis C) Cirrhosis D) Hepatic encephalopathy

D) Hepatic encephalopathy

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent? A) Kanamycin B) Spironolactone C) Cholestyramine D) Lactulose

D) Lactulose Explanation: Lactulose is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

Clinical manifestations of common bile duct obstruction include all of the following except: A) Clay-colored feces B) Jaundice C) Pruritus D) Light-colored urine

D) Light-colored urine Explanation: The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? A) Relieving the client's anxiety B) Controlling bleeding C) Maintaining fluid volume D) Maintaining the airway

D) Maintaining the airway Explanation: Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway can be compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.

The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia? A) Acetazolamide (Diamox) B) Furosemide (Lasix) C) Bumetanide (Bumex) D) Spironolactone (Aldactone)

D) Spironolactone (Aldactone) Explanation: Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? A) The client is avoiding the nurse. B) The client is relaxed and not in pain. C) The client didn't take his morning dose of lactulose (Cephulac). D) The client's hepatic function is decreasing.

D) The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: A) elevated liver enzymes and low serum protein level. B) subnormal clotting factors and platelet count. C) elevated blood urea nitrogen and creatinine levels and hyperglycemia. D) subnormal serum glucose and elevated serum ammonia levels.

D) subnormal serum glucose and elevated serum ammonia levels. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.

A patient has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A) Radiation therapy often results in secondary brain tumors. B) Surgical complications are exceedingly common. C) Diagnosis rarely occurs until the cancer is endstage. D) Metastases are common and respond poorly to treatment.

D. Explanation :Deaths from malignancies of the head and neck are primarily attributable to local-regional metastasis to the cervical lymph nodes in the neck. This often occurs by way of the lymphatics before the primary lesion has been treated. This local-regional metastasis is not amenable to surgical resection and responds poorly to chemotherapy and radiation therapy. This high mortality rate is not related to surgical complications, late diagnosis, or the development of brain tumors.

Which client requires immediate nursing intervention? The client who: a) presents with ribbonlike stools. b) complains of anorexia and periumbilical pain. c) complains of epigastric pain after eating. d) presents with a rigid, boardlike abdomen.

D. Explanation: A rigid, board like abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools.)

The nurse is assessing a client for constipation. Which of the following is the first review that the nurse should conduct to identify the cause of constipation? Choose the correct option a) Review the client's alcohol consumption. b) Review the client's current medications. c) Review the client's activity levels. d) Review the client's usual pattern of elimination.

D. Explanation: Constipation has many possible reasons; assessing the client's usual pattern of elimination is the first step in identifying the cause.

Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? a) Calorie restriction b) Low protein c) Iron restriction d) Low residue

D. Explanation: Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.

A nurse is teaching an elderly client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? a) "I should exercise four times per week." b) "I should eat a fiber-rich diet with raw, leafy vegetables, unpeeled fruit, and whole grain bread." c) "I need to drink 2 to 3 liters of fluids every day." d) "I need to use laxatives regularly to prevent constipation."

D. Explanation: The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.