Unit 6- Inflammation

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?

"I should increase my intake of fresh fruits and vegetables during remissions." A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, the client should follow a low-fiber diet to help minimize bulk in the stools. A client with diverticulosis should follow a high-fiber diet. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids.

A client is admitted for a transurethral resection of the prostate (TURP). Preoperative teaching will include which information?

"You will return from surgery with a catheter in your bladder and fluid flowing into and out of it continuously." A continuous bladder irrigation system is present for a prescribed period of time after a TURP in order to dilute the bleeding and prevent clots from blocking the urinary tract. A three-way catheter is inserted and left in place, usually for 1 to 2 days. The client will not be using a urinal while the catheter is in place, nor will the client have an abdominal incision.

A nurse is assessing the abdomen of a client who was admitted to the emergency department with suspected appendicitis. Identify the area of the abdomen that the nurse would palpate last.

An acute attack of appendicitis localizes as pain and tenderness in the lower right quadrant, midway between the umbilicus and the crest of the ilium. This area would be palpated last in order to determine if pain is also present in other areas of the abdomen.

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Cullen's sign Cullen's sign is evidenced by discoloration at the periumbilical area. This sign may indicate an underlying subcutaneous intraperitoneal hemorrhage. Chvostek's sign is a facial nerve spasm and Trousseau's sign is a carpopedal spasm; both signs occur with hypocalcemia. Broca's area, not sign, is an area within the brain that controls the motor functions involved in speech.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action?

Elevate the ankle. Soft tissue injuries should be treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase the risk of further injury. Morphine is not the drug of choice for pain due to inflammation.

When assessing a client's incision one day after surgery, the nurse sees redness and warmth around the incision site. What action by the nurse is best?

Note the wound edges in the client's chart. Warmth and redness are normal signs of an inflammatory response and do not require interventions such as a cool compress. There are no infectious processes that would require a culture. Blanching does not demonstrate that there is wound infection.

A client arrives to the emergency department with suspected appendicitis. The admitting nurse performs an assessment. Order the following steps according to the sequence in which they are performed. All options must be used.

Obtain a health history. Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. Auscultate bowel sounds in all four quadrants. Percuss all four abdominal quadrants. Gently palpate all four quadrants, saving the painful area for last. The first step in the data collection process is to obtain a health history. Then, the nurse would visually inspect the abdomen. Of the three remaining steps, it is important to auscultate before percussing or palpating the client's abdomen. Touching or palpating the abdomen before listening may actually change the bowel sounds, leading to faulty data.

A child is brought to the emergency department experiencing severe right lower quadrant pain. The child's pulse and respirations are elevated, and there are localized tenderness and sluggish bowel sounds. Shortly after the initial assessment, the child states that the pain has suddenly resolved. Which of the following would the nurse suspect?

The child has signs that the appendix has ruptured. When a child with severe right lower quadrant pain has a sudden relief of pain, a ruptured appendix should be suspected. None of the other options reflects this symptom change.

A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis?

a low-fat, bland diet distributed over five to six small meals daily A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition.Dietary protein and fiber are not directly related to pancreatitis.Although calcium is important, the low-fat content is more significant.The hyperglycemia of acute pancreatitis is usually transient and does not require long-term dietary modification.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?

a middle-aged man with no injuries who has rapid respirations and coughs The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous childbirth. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to their back. Which intervention takes priority for this client?

administering morphine I.V. as ordered The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

Which meal would be appropriate for the child with osteomyelitis to choose?

beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs, cheese, meat, fish, and beans are the best sources of these nutrients.

When evaluating a client for complications of acute pancreatitis, the nurse should observe for

decreased urine output. Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn't related to acute pancreatitis.

A client comes to the emergency department reporting pain in the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder?

degenerative joint disease Obesity predisposes the client to degenerative joint disease. Obesity isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease.

When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet?

high purine To control uric acid calculi, the client would follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?

increased serum amylase and lipase levels Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, what is an expected outcome?

less difficulty breathing Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

A client is admitted to the emergency department with abdominal pain. The client's caregiver states the pain began about 12 hours ago. The nurse notes the client has a temperature of 100.8° F (38.2° C) and nausea. The client vomited once. Which abdominal area would be most appropriate for the nurse to assess?

right lower abdominal quadrant The client's symptoms indicate appendicitis. Therefore, the nurse should assess the right lower abdominal quadrant. The nurse would assess the left lower abdominal quadrant to detect descending and sigmoid colon problems; right upper quadrant to detect gallbladder disease; and the left upper quadrant to detect pancreatitis.

A client is diagnosed with contact dermatitis. Which medication should the nurse expect to be prescribed to treat this disorder?

topical corticosteroid Contact dermatitis is an area of skin inflammation caused by a hypersensitivity response or chemical irritation. Medications to treat contact dermatitis include a topical corticosteroid to reduce inflammation. Contact dermatitis would not be treated with an intravenous corticosteroid. Because contact dermatitis is not caused by a bacterial infection, an intravenous or oral antibiotic is not required.

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect?

with each meal and snack In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.

A client presents to the community clinic with a viral infection and swollen lymph nodes. When assessing the lymph nodes of the head and neck, the nurse notes hard and irregular shaped nodes in the submandibular region. When documenting the site of the lymph nodes, which are the area of concern?

The submandibular lymph nodes are found halfway between the angle and tip of the mandible. The submandibular lymph nodes account for approximately 70% of the salivary volume produced. Hard and irregularly shaped lymph nodes are a concern for more serious conditions.

The nurse is caring for a 3-month-old infant, who had a cleft palate and cleft lip surgical repair. Which assessment data would indicate a postoperative complication from the surgery?

suture line surrounded by erythema There is a risk for infection in the suture line if it is not kept clean and dry. Signs of infection would include erythema or foul drainage from the suture line and fever. Crying intermittently is a normal assessment finding and the nurse should be prepared with liquids or formula. A suture line may be swollen in the immediate postoperative period, but its appearance will improve with time. A Logan bar may be used to hold the suture line in place.

A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective?

"I know that this disease is serious and can lead to asthma." By saying that bronchiolitis places the child at risk for developing asthma, the parent demonstrates understanding of the infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation.

The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client becomes upset when the health care provider (HCP) persists in asking about alcohol intake. What should the nurse tell the client about the reason for these questions?

"There is a strong link between alcohol use and acute pancreatitis." Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

Administer epinephrine. To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent adrenergic agonist, as ordered. The healthcare provider is likely to order additional medications, such as antihistamines and corticosteroids; if these medications do not relieve the respiratory compromise associated with anaphylaxis, the nurse should prepare to intubate the client. The nurse should continue to monitor the client's vital signs; a client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring. However, administering epinephrine is the first priority.

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?

Blood supply to the stoma has been interrupted. 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 client with acute lymphocytic leukemia is receiving vincristine. Prior to infusing the drug, the nurse administers diphenhydramine. What should the nurse tell the client about the purpose of taking diphenhydramine?

Diphenhydramine decreases incidence of a reaction to the vincristine. Diphenhydramine is an antihistamine. This drug helps reduce the incidence of an allergic response by blocking the release of histamine. Diphenhydramine also possesses anticholinergic effects and can reduce the incidence of nausea and vomiting for clients receiving chemotherapy. Although diphenhydramine may promote sleep, it is not the primary reason for its administration in this instance. Diphenhydramine will not reduce anxiety or potentiate the action of the vincristine.

The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that the wound is inflamed?

Localized warmth over the incisional area. Localized warmth over the incisional area indicates that inflammation is present and could indicate the presence of an infection.Serous-sanguineous drainage from a wound drain is normal in the early postoperative phase.Dried, bloody drainage is also considered to be a normal finding.A slightly pink skin color around staples or sutures is to be expected as the skin is irritated by the presence of the materials.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet. A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake is not necessary because chronic pancreatitis is not associated with hyponatremia or fluid loss.

A male client comes to the clinic with complaints of pain in his great toe. The client reports that the pain is worse at night. Assessment reveals tophi. The nurse suspects the client has

gouty arthritis. Gout results from the inability to metabolize purines. This condition is most commonly seen in men and usually affects the legs, feet, and knees. Osteoarthritis is caused by degeneration of the joints. Rheumatoid arthritis is a systemic disorder more common in women of childbearing age. Reactive arthritis is seen with infections and is most common in young adult males.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

The parent of a 16-year-old adolescent calls the emergency department, suspecting the adolescent's abdominal pain may be appendicitis. In addition to pain, the adolescent has a temperature of 100°F (37.7°C) and has vomited twice. What should the nurse tell the parent?

"Bring your child into the emergency department immediately before the appendix has a chance to rupture." Abdominal pain, low-grade fever, and vomiting are cardinal signs of appendicitis. The nurse should instruct the parent to take the child to the emergency department. Telling the parent to give the child a laxative is inappropriate because if appendicitis is the cause of the pain the appendix may rupture as a result of the drug. Appendicitis can occur at any age. Rebound tenderness is a symptom of appendicitis, but this finding would be found in the right lower quadrant, not the left.

The caregivers of a school-aged client with a new diagnosis of ulcerative colitis ask the nurse how to manage the condition at school. How should the nurse respond? Select all that apply.

"Work with the school nurse to develop a plan." "Your child will need to drink plenty of liquids at school." "Your child should keep a change of clothing at school." Ulcerative colitis is a chronic inflammatory bowel disorder with exacerbations and remissions. In ulcerative colitis the colon develops continuous ulcerations that cause the common symptoms of pain and bloody diarrhea. Drugs such as antiinflammatory medications, antidiarrheals, and immunosuppressants have been used for management. A child with a chronic condition should have an action plan with the school nurse to provide needed medication and monitor symptoms. A change of clothing may be needed if clothing is soiled as a result of diarrhea. The child should be careful to avoid foods that increase symptoms (commonly raw vegetables, dairy products, and gas-producing foods such as beans, broccoli, or cabbage). Most school lunches are not individualized to a specific child. Liquids are important to prevent dehydration from diarrhea.

A toddler taking penicillin for acute otitis media developed a maculopapular rash 24 hours ago after 3 days of therapy. The parents report no other abnormal symptoms. The nurse takes what initial action?

Assess chest sounds and oxygen saturation. It is relatively common for children to experience delayed hypersensitivity reactions to penicillin that are isolated to cutaneous eruptions. Often, it is safe for these children to receive penicillins in the future. However, the nurse must ensure this current reaction is not more serious than it appears. Because a toddler cannot adequately communicate symptoms, the nurse assesses the client's respiratory status to ensure there is no evidence of bronchoconstriction that could suggest anaphylaxis. Once a full assessment has been completed, the nurse can then request the appropriate treatments be initiated.

The nurse assesses a child with fever, sensitivity to light, and a red rash on the back. How will the nurse assess for Kernig's sign?

Have the child lie supine with flexed knees, then ask the child to extend the knees. Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign: place the client is in the supine position with knees flexed; ask the child to flex a leg at the hip so that the thigh is brought to a position perpendicular to the trunk; then ask the child to extend the knee. If meningeal irritation is present, the knee can't be extended, and attempts to extend the knee result in pain. Chvostek's sign and Trousseau's sign are indicators of calcium deficiit. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. Trousseau's sign is elicited by inflating a blood pressure cuff on the arm and observing the reaction of the metacarpal phalangeal joints, interphalangeal joints, and thumb. Brudzinski's sign is used to test for nucchal rigidity by flexing the client's neck and observing for leg and knee flexion.

A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100°F (37.8°C). The nurse questions the client about a past diagnosis of what condition?

inflammatory bowel disease (IBD) IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort with colorectal cancer. A client with diverticulitis commonly reports chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

A nurse assesses a client with suspected bacterial meningitis. Which documented finding of meningeal irritation suggests this diagnosis? Select all that apply.

nuchal rigidity positive Brudzinski's sign positive Kernig's sign photophobia Irritation of the meninges of the brain can be caused by a virus or bacteria. Signs of meningeal irritation include nuchal rigidity, positive Brudzinski's and Kernig's signs, and photophobia. Other signs of meningeal irritation are exaggerated and symmetrical deep tendon reflexes as well as opisthotonos (a spasm in which the back and extremities arch backward so that the body rests on the head and heels). Tinnitus or ringing in the ears is not a common symptom. Babinski's reflex is a reflex action of the toes that reflects corticospinal tract disease in adults.

The nurse is caring for a preterm neonate in the neonatal intensive care unit receiving enteral feedings. The nurse notes an increase in respiratory rate, increase in regurgitation of feeding solution, and moderate abdominal distention. What action does the nurse take based on these findings?

stop the enteral feeding Necrotizing enterocolitis (NEC) is an inflammation of the bowel that occurs most often in preterm neonates who are receiving enteral feedings. The cause of the condition is not well understood, but the nurse should recognize the risk in this neonate and immediately stop the enteral feeding. Once this is done, the nurse ensures intravenous access is available, completes additional relevant assessments and notifies the healthcare provider of the findings. The nurse should not wait to complete these steps as NEC can quickly progress to sepsis and other complications. Improper placement of the feeding tube would not cause all the symptoms presented, so the nurse's focus should be NEC.

A client is recovering from an abdominal-perineal resection. To promote wound healing after the perineal drains have been removed the nurse should encourage the client to:

take sitz baths. Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry.A shower will not adequately clean the perineal area.Moist dressings may promote wound contamination and delay healing.A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort.

An adolescent client scheduled for an emergency appendectomy is to be transferred directly from the emergency department to the operating room. Which statement by the client should the nurse interpret as most significant?

"All of a sudden it does not hurt at all." Sudden relief of pain in a client with appendicitis may indicate that the appendix has ruptured. Rupture relieves the pressure within the appendix but spreads the infection to the peritoneal cavity. Periumbilical pain (pain centered around the navel), vomiting, and abdominal tenderness on palpation are common findings associated with appendicitis.

The nurse is providing information to the parents of a child newly diagnosed with juvenile arthritis. Which statements by the parents indicate understanding of the teaching? Select all that apply.

"I help my child perform daily range-of-motion exercises." "I give my child NSAIDs three times a day." "I apply heat pads to the joints when my child is having pain." NSAIDs are taken one to four times a day by children with juvenile arthritis and are given to control pain and inflammation as well as malaise and irritability. NSAIDs should be given even when the child is pain free because the anti-inflammatory properties of the drugs are key to preventing pain. Assisting the child to perform daily range-of-motion exercises and applying heat pads to joints when in pain are also correct interventions. The child should be encouraged to attend school regularly and to exercise.

Which statement indicates the client understands the lifestyle modifications required when managing ulcerative colitis?

"I'll have to stop smoking." Tobacco, caffeine, and alcohol are gastrointestinal stimulants and should be avoided by clients with ulcerative colitis.High-fiber foods such as popcorn and nuts are not allowed because of potential gastrointestinal irritation.

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. What should the nurse tell the client?

"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.

A child is admitted to the emergency department and diagnosed with a suspected ruptured appendix. The parents are anxious about the child's condition and ask the nurse what to expect for immediate treatment. What is the best response by the nurse?

"We will be preparing your child for emergency surgery." Preparing for emergency surgery is the priority action at this point in time. Antibiotic therapy would be initiated after surgery in addition to addressing pain control and dietary revision.

Which goal is most important for a client with acute pancreatitis?

The client reports minimal abdominal pain. Abdominal pain can be a significant problem in acute pancreatitis. An expected outcome is to decrease or eliminate the pain the client is experiencing. Patterns of bowel elimination and liver function are not typically affected by pancreatitis. The client should avoid alcohol.

A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, what should the nurse do to ensure client comfort and safety?

Start an IV infusion of normal saline. The nurse administers the PRBCs using a separate infusion line and appropriate tubing, with normal saline as the priming solution. It is not necessary to discontinue the TPN infusion or wait until the TPN infusion is completed.

The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication?

Take it with a full glass (240 mL) of water. Adequate fluid intake of at least eight glasses a day prevents crystalluria and stone formation during sulfasalazine therapy.Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses.Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.

Pancrelipase, an enzyme replacement, has been prescribed for a client with chronic pancreatitis. Which points should the nurse include in the client's teaching plan about the drug?

The client should be careful not to inhale the powder when mixing it with food. When mixing the enzyme (lipase, protease, amylase) powder into food, the client should be careful not to inhale it as the powder may trigger an asthma attack.The enzymes are taken before or with each meal, not after.The drug does not need to be stored in the refrigerator.The client should not chew the capsules.

The nurse is caring for a client with juvenile idiopathic arthritis. What will the nurse include in the client's plan of care? Select all that apply.

administer ibuprofen for pain encourage a well-balanced diet measure growth and development assess joints for swelling and deformity Juvenile idiopathic arthritis affects the joints. Ibuprofen is a drug of choice, and eating a well-balanced diet helps in weight management. The joints can become deformed and swollen. Growth and development can be affected due to the changes in the joints.

A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for:

bloody, diarrheal stools. Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea.Constipation is not a sign or symptom of ulcerative colitis.Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis.Alternating diarrhea and constipation is associated with irritable bowel syndrome.

A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects to prepare the client for which diagnostic study?

colonoscopy with biopsy Crohn's disease is an inflammatory bowel disorder characterized by inflammation, ulceration, and edema of the bowel wall (typically involving the terminal ileum). Colonoscopy with biopsy are the primary procedures used to establish the diagnosis; a barium enema also may be indicated. Although genetics may play a role in Crohn's disease, genetic testing isn't part of the diagnostic workup. Cystoscopy visualizes the bladder and urinary tract and isn't indicated for this client. Myelography is a radiographic procedure used to evaluate the spinal cord.

A nurse is calling report to the medical-surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply.

cramping pain in the left lower abdominal quadrant bowel irregularity intervals of diarrhea Acute diverticulitis is a common digestive disease typically found in the large intestine. Signs and symptoms of acute diverticulitis include bowel irregularity, intervals of diarrhea, abrupt onset of cramping pain in the left lower abdomen, and a low-grade fever. Esophagitis, heartburn, and hiccuping are not signs of the disorder.

A client with chronic myelogenous leukemia is taking imatinib. The nurse should instruct the client to report which adverse effect of this drug?

edema Imatinib works by inhibiting the proliferation of abnormal cells. Adverse effects include edema and GI irritation. Typical effects of this drug do not include edema, numbness and tingling, bloody stools, or persistent cough. If the client has these symptoms, they may relate to disease occurrence or recurrence.

The health care provider has prescribed oxycodone to relieve pain for a client with pancreatitis. The client is not obtaining pain relief. When contacting the health care provider to explain the situation, background, and assessment, the nurse should recommend which medication for this client?

meperidine hydrochloride Meperidine hydrochloride, a strong opioid analgesic, effectively reduces the pain of acute pancreatitis.Cimetidine, a histamine receptor antagonist, decreases gastric acidity.Morphine sulfate and codeine sulfate are contraindicated in pancreatitis because they can cause spasm of the pancreatic ducts and exacerbate pain.

A client with joint pain, tenderness and swelling has been admitted to the hospital. A disease modifying anti-rheumatic drug (DMARD) is prescribed by the healthcare provider. Which medication should the nurse expect to administer?

methotrexate Methotrexate is considered a first-line DMARD for most clients with rheumatoid arthritis (RA). NSAIDs, such as aspirin, cannot be tolerated. Ferrous sulfate is not used to treat RA. Prednisone may be used to control inflammation when NSAIDs cannot be used.

A client with chronic pancreatitis should be assessed for which finding?

nausea and vomiting Common manifestations of chronic pancreatitis include nausea, vomiting, and intermittent pain. Chronic pancreatitis does not cause confusion or agitation. There is no change in vital signs, and there are no musculoskeletal manifestations such as muscle twitching.

A client informs the nurse that the venipuncture site "hurts." The nurse should assess the site for which findings? Select all that apply.

redness pain coolness blanching firmness edema The venipuncture site must be assessed for signs of infection (redness and pain at the puncture site), infiltration (coolness, blanching, and edema at the site), and thrombophlebitis (redness, firmness, pain along the path of the vein, and edema).

The school nurse is teaching caregivers of school-age children about prevention of rheumatic fever. What should be included?

take the child to a healthcare provider when strep throat is suspected Rheumatic fever is caused by untreated strep throat. Aspirin (acetylsalicylic acid) should not be given to children because of the risk of Rhyes syndrome. Conjunctivitis is not associated with rheumatic fever. Antibiotics should be taken until the prescription is gone.

Which is an appropriate nursing goal for the client who has ulcerative colitis? The client:

verbalizes the importance of small, frequent feedings. small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation.The client does not need to maintain a daily record of intake and output unless an exacerbation of the disease occurs.A heating pad should not be applied to the intestine as it is inflamed.It is not inevitable that the client will require surgery to treat the ulcerative colitis as about 85% respond favorably to conservative therapy. If the severity of the disease mandates surgery, the colon will be removed, resulting in an ileostomy.

A nurse is caring for a 14-year-old boy who arrives in the office stating abdominal pain with nausea and vomiting for the past 24 hours. The mother reports the client experiencing sharp pain when hitting a pothole along the road. The vital signs are: temperature, 101.6°F (37.8°C); pulse, 92 beats/minute; respirations, 24 breaths/minute; blood pressure, 142/82 mm Hg. As the nurse is collecting all data, in which location of the abdomen will the nurse obtain definitive assessment data?

All of the data provided (abdominal pain, nausea with vomiting, elevated temperature, and rebound tenderness when hitting a pothole) indicate a potential appendicitis. Appendicitis typically begins with anorexia, nausea, and vomiting for the first 12 to 24 hours. Abdominal pain, a late sign, is usually diffuse at first and gradually localizes to the right lower quadrant. The sharpest pain should be noted at McBurney's point, which is one-third of the way between the anterior and superior iliac crest and the umbilicus.

When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction?

Apply ice to the fracture site. Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding; heat to the fracture site would not be used because it may increase swelling and bleeding. There is no evidence that this is an open fracture where there is a break in the skin warranting discharge instructions regarding signs of infection. Ankle dorsiflexion has no therapeutic use after a toe fracture. It is unlikely the client would need crutches after a toe fracture.

When a client has an acute attack of diverticulitis, what should the nurse do first?

Assess the client for signs of peritonitis. The nurse should first assess the client for signs of peritonitis. Complications of diverticulitis include perforation with peritonitis, abscess, and fistula formation, bowel obstruction, ureteral obstruction, and bleeding. A computed tomography (CT) scan with oral contrast is the test of choice for diverticulitis. A client with acute diverticulitis does not receive a barium enema or colonoscopy because of the possibility of peritonitis and perforation. With acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. The client is kept on NPO status; parenteral fluid therapy is provided.

The nurse is caring for a child with an acute exacerbation of asthma. Oral methylprednisolone has been ordered. Which of the following actions is most important for the nurse to take when administering this medication?

Give the medication with food. Giving the medication with food helps reduce gastric irritation. Oral doses of corticosteroids should be given in the morning.

The client with an exacerbation of ulcerative colitis is to be on bed rest with bathroom privileges. What will indicate to the nurse that being on bed rest has had the desired outcome?

The client has slowed intestinal peristalsis. Although bed rest does help conserve energy and promotes comfort, falling is not a risk, and its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.

The client has chronic pancreatitis. What should the nurse teach the client to do to monitor the effectiveness of pancreatic enzyme replacement?

Observe stools for steatorrhea. If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.

A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101° F (38° C) The client also reports a headache and appears flushed. In what order, from first to last, should the nurse perform the actions? All options must be used.

Stop the blood infusion. Infuse normal saline to keep the vein open. Obtain a blood culture from the client. Send the blood bag and administration set to the blood bank. The client is experiencing a septic reaction to the blood transfusion. The nurse first stops the infusion and notifies the health care provider (HCP) and blood bank; then the nurse uses an infusion of normal saline to keep the vein open, and follows by obtaining a sample of the client's blood for a blood culture. Lastly, the nurse sends the blood bag and the administration set to the blood bank for culture.

A client who is receiving chemotherapy develops stomatitis. What should the nurse instruct the client to do?

Use a soft-bristled toothbrush after each meal. Stomatitis is an inflammation of the mucous membranes of the mouth resulting from chemotherapy. Using a soft-bristled toothbrush prevents further bleeding and irritation to the already irritated gums and mucous membranes. Hydrogen peroxide can further irritate the mouth. Fluids need to be lukewarm instead of hot; dental floss can be used if it is done gently.

A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis?

Wash the perineum with warm water and soap, cleaning from front to back. Acute pyelonephritis usually begins with a bacterial infection of the lower urinary tract via the ascending urethral route; most infections are due to gram-negative bacilli, such as Escherichia coli, normally found in the gastrointestinal tract. Thorough perineal care using soap and warm water, and cleansing from front to back, decreases the likelihood that organisms will be introduced into the urinary tract and ascend upward toward the kidneys. Although preventing and treating all infections are appropriate, fungal infections from the feet and bacterial infections in the throat or skin are less likely to be immediate sources of infection causing pyelonephritis.

The nurse is teaching a group of women about risk for varicose veins. Which client is at risk for varicose veins?

a client who has had thrombophlebitis Secondary varicosities can result from previous thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebrovascular accident, anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins.

A nurse should expect to administer which medication to a client with gout?

colchicine A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it doesn't treat gout.

A 5-year-old is admitted to the pediatric unit with diagnosis of possible intussusception. Which assessment data supports this diagnosis? Select all that apply.

currant jelly stools abdominal pain abdominal distention Intussusception is when a portion of the intestine telescopes into another part of the intestine causing the walls of the intestine to press against each other. Inflammation, edema and hemorrhage occur leading to abdominal symptoms of currant jelly stools (a combination of blood and mucus), abdominal pain which is sharp at times and abdominal distention. Constipation, not diarrhea, is also common from the swelling and obstructive flow of stool. Tarry, black stools are common in intestinal bleeding and ulcers.

A client has been placed on long-term sulfasalazine therapy for treatment of ulcerative colitis. The nurse should encourage the client to eat which foods to help avoid the nutrient deficiencies that may develop as a result of this medication?

green, leafy vegetables In long-term sulfasalazine therapy, the client may develop folic acid deficiency. The client can take folic acid supplements, but the nurse should also encourage the client to increase the intake of folic acid in his diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not good sources of folic acid.

Which symptom would the nurse most likely observe in a client with cholecystitis from cholelithiasis?

nausea after ingestion of high-fat foods A client with cholecystitis from cholelithiasis may experience nausea, vomiting, abdominal discomfort, and other gastrointestinal symptoms after eating high-fat foods. This is due to decreased fat absorption related to lack of normal bile flow from the gallbladder.Black stools are indicative of gastrointestinal bleeding, not gallbladder disease.Clients are more likely to have a low-grade fever.Clients are more likely to have an elevated white blood cell count due to inflammation.

The nurse is assessing a client with suspected acute cholecystitis. Which clinical manifestation is indicative of acute cholecystitis? Select all that apply.

nausea and vomiting leukocytosis tenderness in right upper quadrant Nausea and vomiting, leukocytosis, and tenderness in the right upper quadrant are classic clinical manifestations of acute cholecystitis. Pain associated with voiding and bleeding mucous membranes are not clinical manifestations related to acute cholecystitis.

A client with rheumatoid arthritis tells the nurse that she feels "quite alone" in adjusting to changes in her lifestyle. Which response by the nurse will be most effective?

telling the client about her community's arthritis support group. The client should be encouraged to join the community arthritis support group so that she can share her feelings with others who are facing similar experiences with this chronic illness and can identify with her concerns. A hobby will not help her resolve her feelings of being alone. Seeking counseling or discussing her feelings with a minister may be helpful, but these activities will not necessarily help the client to understand that there are many individuals who must adjust their lifestyles because of arthritis and that she is not alone.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

trigeminal neuralgia Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of

increasing fluid intake to prevent dehydration. Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

The nurse working in an internal medicine clinic receives four phone calls from clients with chronic pancreatitis. Which client should the nurse contact first?

The client reporting increased thirst and hunger. Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin. Increased thirst and hunger are symptoms of diabetes. Chronic abdominal pain can be recurrent for months to years. The client with the need for pancreatic enzymes prescription refill is not in acute distress and can be called back later. A symptom of chronic pancreatitis is steatorrhea (fatty stools) and can become severe. The nurse should follow-up with the client to assess for volume and frequency of the stools, however, this client is not the priority.

A nurse is obtaining a health history from a male senior citizen. The client states that he is having urinary hesitancy, slight dysuria, and dribbling. He denies reports of hematuria. Identify the area where the nurse anticipates the primary cause of the urinary dysfunction.

The walnut-sized prostate gland lies beneath the bladder and surrounds the urethra. When the prostate gland becomes enlarged, which commonly occurs as a male ages, urination becomes affected as the prostate gland narrows the passage of urine through the urethra.

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104° F (40° C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3 (16,000 X 109/L). What is priority for nursing intervention?

airway obstruction The child's signs and symptoms in conjunction with the acute onset suggest possible croup or epiglottitis. The priority diagnosis at this time is airway obstruction. The airway may become completely occluded by the epiglottis at any time. Although the child has an infection, and the client has respiratory distress, the immediate priority is to establish and maintain a patent airway. No evidence is provided to support the potential for aspiration.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain?

an exercise routine that includes range-of-motion (ROM) exercises Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution?

anaphylactic reaction The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion immediately, but leave the IV line intact, and notify the health care provider. Usually, an antihistamine such as diphenhydramine hydrochloride) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood administration. The administration should not cause pain unless it is extravasating out of the vein, in which case the IV administration should be stopped. Administration of a unit of blood should not affect the level of consciousness.

The nurse should teach clients about which potential risk factor for the development of colon cancer?

history of inflammatory bowel disease A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet.

Which diet would be most appropriate for the client with ulcerative colitis?

high-protein, low-residue Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which result indicates the presence of inflammation?

leukocytosis Leukocytosis, an increased white blood cell count, indicates the presence of inflammation, infection, or a leukemia process. In inflammation and infection, the client's sedimentation rate is increased. Thrombocytopenia, a platelet deficiency, occurs in the client with leukemia, immunocompromised client, client with aplastic anemia, or client with other conditions. Erythrocytosis, an elevation of the red blood cell count, occurs in polycythemia vera.

A 14-year-old brought to the emergency department with right lower quadrant pain is tentatively diagnosed with acute appendicitis. The nurse should further assess the client for which sign or symptom?

low-grade fever The most common manifestations of appendicitis include right lower quadrant pain, localized tenderness, and a low-grade fever. Other signs of inflammation, including increased pulse and respiratory rates, may be present. Costovertebral angle tenderness and gross hematuria are associated with urologic problems. Widening pulse pressure is seen in increased intracranial pressure.

The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client?

palpation The nurse caring for the client with right lower quadrant abdominal pain would perform a complete abdominal assessment including inspection, auscultation, percussion, and palpation, but palpation is the most important. The nurse must assess for tenderness with palpation, which is associated with inflammation of the peritoneal cavity and may be caused by appendicitis. The report of tenderness with palpation is often the defining factor when planning care for the client with right lower quadrant pain.

A client has been admitted to the emergency department with severe mid-epigastric, upper quadrant abdominal pain. Based on the signs and symptoms and laboratory data documented in the chart, the nurse would anticipate preparing for which diagnosis?

pancreatitis The assessment findings combined with the laboratory results suggest pancreatitis. The pancreas is situated behind the stomach in the upper quadrant. Signs and symptoms of pancreatitis include severe mid-epigastric, upper quadrant abdominal pain, fever, nausea, and vomiting. Inflammation of the pancreas results in leukocytosis. Injured ?-cells are unable to produce insulin, leading to hyperglycemia, which may be as high as 500 to 900 mg/dl (27.75 to 49.95 mmol/L). Lipase and amylase levels become elevated as the pancreatic enzymes leak from injured pancreatic cells. Calcium becomes trapped as fat necrosis occurs, leading to hypocalcemia. Peptic ulcer, Crohn's disease, and irritable bowel syndrome do not cause amylase or lipase levels to increase.

A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound?

pericardial friction rub A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell's murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the nurse's diagnosis?

recent weight loss and temperature elevation Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions?

"You are not allowed anything by mouth so that your pancreas can rest." The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management and fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client?

Refer the client to her health care provider for evaluation and treatment of the pain. The nurse seeing this client should refer her to an HCP for further evaluation of the pain. This referral would allow a more definitive diagnosis and medical interventions that may include surgery. Referral would occur because of her high pain rating as well as the other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile does not move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. Although education should be a continuous strategy, with pain at this level, a brief explanation is most appropriate. Major emphasis should be placed on determining the cause and treating the pain. It is not appropriate for the nurse to diagnose pain at this level as heartburn. Discussing nutritional strategies to prevent heartburn are appropriate during pregnancy, but not in this situation. Acetaminophen is an acceptable medication to take during pregnancy but should not be used on a regular basis as it can mask other problems.

What information should the nurse include when developing the teaching plan for the parents of a child with juvenile idiopathic arthritis who is being treated with naproxen?

The nurse should be called before giving the child any over-the-counter medications. The first group of drugs typically prescribed is the nonsteroidal anti-inflammatory drugs, which include naproxen. Once therapy is started, it takes hours or days for relief from pain to occur. However, it takes 3 to 4 weeks for the anti-inflammatory effects to occur, including reduction in swelling and less pain with movement. Naproxen is included in only a few over-the-counter medications, but aspirin is in several. The family should check with the nurse before giving any over-the-counter medications. Toxicity or GI bleeding may occur when nonsteroidal anti-inflammatory drugs are combined. The missed dose will need to be made up to maintain the serum level and to maintain therapeutic effectiveness of the drug.

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. Which additional assessment finding will the nurse assess for?

severe abdominal pain with direct palpation or rebound tenderness Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of what would be significant to this client's diagnosis?

ulcerative colitis A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Crohn's disease does not have inflammatory symptoms, but rather more abdominal pain related. A family history of peptic ulcers is not a genetic risk factor as well as appendicitis.

When the nurse is obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which question would be most helpful in eliciting data to help support the diagnosis?

"Where did the pain start?" The most helpful question would be to determine the location of the pain when it started. The pain associated with appendicitis usually begins in the periumbilical area and then progresses to the right lower quadrant. After the nurse has determined the location of the pain, asking about what was done for the pain would be appropriate. Asking about the child's usual bowel movement pattern is a general question unrelated to child's condition. Children with appendicitis may have diarrhea or constipation. Additionally, knowledge about the child's usual pattern would not be a priority because the child with appendicitis typically is not hospitalized long enough to reestablish the normal pattern. Although the characteristics of the pain are important, asking if the pain is continuous or intermittent is vague and general because the pain could be associated with numerous conditions. With appendicitis, the client's pain may begin as intermittent, but it eventually becomes continuous.

A nurse is assessing a client with right flank pain, fever, and chills. A urine culture is obtained, and a diagnosis of suspected right pyelonephritis is documented. When instructing the client on the diagnosis, the nurse uses a diagram of the urinary structures. Identify the area associated with the diagnosis.

Pyelonephritis is a type of urinary tract infection that affects one or both kidneys. Right pyelonephritis is on the right side of the client's body but would be documented on the left in the anatomical position. Bacteria and viruses can move to the kidneys from the bladder or can be carried from other body systems through the bloodstream causing the disease process.

The nurse is planning care for a client who has an allergy to latex. What intervention would be the priority for the nurse to include in the plan of care?

Place latex-free, powder-free gloves at client's bedside. Latex-free, powder-free gloves reduce the risk of respiratory exposure to latex. Having them conveniently located will enhance staff adherence, so this is the most important intervention. Using oil-based hand lotion should be avoided when wearing latex gloves because this increases risk of latex breakdown and can increase latex exposure for the person wearing the gloves. However, the client can have oil-based lotions applied to the skin as this is not contraindicated. Obviously, the nurse would wear latex-free gloves for application, or no gloves at all if no contact with body fluids is expected. Having a roommate with a latex catheter does not pose a risk of direct exposure for the client. Clients with latex allergies should have clear signage but do not require a private room.

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/minute, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?

temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24 breaths/min This client is exhibiting signs of sepsis, and the nurse should notify the health care provider. The client has three signs indicating sepsis: temperature >101.0°F (38.3°C) (or <96.8°F [36°C]), HR >90 bpm, and RR >20 breaths/min. At least two of these variables are required to diagnose sepsis.

The nurse is teaching a client about the pathophysiology of asthma. Place in chronological order the sequence of an asthma attack. All options must be used.

trigger by stimulus inflammation mucous production airflow limitation breathlessness acute asthma attack Asthma is triggered by a stimulus. The stimulus may be environmental, stress related, or medication related. Inflammation in the airways occurs as a response to the stimulus, followed by an increase in mucus production. The presence of inflammation and mucous narrow the bronchi, causing limited airflow. At this point, the client experiences breathlessness, chest tightness, and wheezing—all symptoms of an acute asthma attack.