Ch. 57 Flashcards
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?
a.
Severe, steady right lower quadrant pain
b.
Abdominal pain associated with nausea and vomiting
c.
Marked peristalsis and hyperactive bowel sounds
d.
Abdominal pain that increases with knee flexion
ANS: A
Right lower quadrant pain, specifically at McBurney’s point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.
DIF: Remembering/Knowledge REF: 1169
A nurse cares for an older adult client who has Salmonella food poisoning. The client’s vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first?
a.
Apply oxygen via nasal cannula.
b.
Administer intravenous fluids.
c.
Provide perineal care with a premedicated wipe.
d.
Teach proper food preparation to prevent contamination.
ANS: B
Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination.
DIF: Applying/Application REF: 1173
A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client’s teaching?
a.
“Drink plenty of fluids to prevent dehydration.”
b.
“You should only drink 1 liter of fluids daily.”
c.
“Increase your protein intake by drinking more milk.”
d.
“Sips of cola or tea may help to relieve your nausea.”
ANS: A
The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.
DIF: Applying/Application REF: 1173
After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
a.
“I will let my husband do all of the cooking for my family.”
b.
“I’ll take the ciprofloxacin until the diarrhea has resolved.”
c.
“I should wash my hands with antibacterial soap before each meal.”
d.
“I must place my dishes into the dishwasher after each meal.”
ANS: B
Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year.
DIF: Applying/Application REF: 1173
A nurse assesses a client who is hospitalized with an exacerbation of Crohn’s disease. Which clinical manifestation should the nurse expect to find?
a.
Positive Murphy’s sign with rebound tenderness to palpitation
b.
Dull, hypoactive bowel sounds in the lower abdominal quadrants
c.
High-pitched, rushing bowel sounds in the right lower quadrant
d.
Reports of abdominal cramping that is worse at night
ANS: C
The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn’s disease. A positive Murphy’s sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn’s disease. Nightly worsening of abdominal cramping is not consistent with Crohn’s disease.
DIF: Applying/Application REF: 1182
After teaching a client with diverticular disease, a nurse assesses the client’s understanding. Which menu selection made by the client indicates the client correctly understood the teaching?
a.
Roasted chicken with rice pilaf and a cup of coffee with cream
b.
Spaghetti with meat sauce, a fresh fruit cup, and hot tea
c.
Garden salad with a cup of bean soup and a glass of low-fat milk
d.
Baked fish with steamed carrots and a glass of apple juice
ANS: D
Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.
DIF: Applying/Application REF: 1187
A nurse cares for a teenage girl with a new ileostomy. The client states, “I cannot go to prom with an ostomy.” How should the nurse respond?
a.
“Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance.”
b.
“The pouch won’t be as noticeable if you avoid broccoli and carbonated drinks prior to the prom.”
c.
“Let’s talk to the enterostomal therapist about options for ostomy supplies and dress styles.”
d.
“You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable.”
ANS: C
The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.
DIF: Applying/Application REF: 1180
After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client’s understanding. Which statement by the client indicates a need for additional teaching?
a.
“I’ll rinse my rectal area with warm water after each stool and apply zinc oxide ointment.”
b.
“I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel.”
c.
“I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry.”
d.
“I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.”
ANS: B
Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.
DIF: Applying/Application REF: 1179
After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
a.
“I will avoid large crowds and people who are sick.”
b.
“I will take this medication with my breakfast each morning.”
c.
“Nausea and vomiting are common side effects of this drug.”
d.
“I must wash my hands after I play with my dog.”
ANS: B
Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.
DIF: Applying/Application REF: 1183
A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, “I am having trouble swallowing this pill.” Which action should the nurse take?
a.
Contact the clinical pharmacist and request the medication in suspension form.
b.
Empty the contents of the capsule into applesauce or pudding for administration.
c.
Ask the health care provider to prescribe the medication as an enema instead.
d.
Crush the pill carefully and administer it in applesauce or pudding.
ANS: C
Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider’s order.
DIF: Applying/Application REF: 1176
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?
a.
Inspection of oral mucosa
b.
Recent dietary intake
c.
Heart rate and rhythm
d.
Percussion of abdomen
ANS: C
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.
DIF: Applying/Application REF: 1172
A nurse assesses a client with Crohn’s disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
a.
Distended abdomen
b.
Temperature of 100.0° F (37.8° C)
c.
Loose and bloody stool
d.
Lower abdominal cramps
ANS: A
The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client’s provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn’s disease.
DIF: Applying/Application REF: 1179
A nurse reviews the chart of a client who has Crohn’s disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?
a.
Serum potassium of 2.6 mEq/L
b.
Client ate 20% of breakfast meal
c.
White blood cell count of 8200/mm3
d.
Client’s weight decreased by 3 pounds
ANS: A
Fistulas place the client with Crohn’s disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.
DIF: Applying/Application REF: 1184
After teaching a client who has a new colostomy, the nurse provides feedback based on the client’s ability to complete self-care activities. Which statement should the nurse include in this feedback?
a.
“I realize that you had a tough time today, but it will get easier with practice.”
b.
“You cleaned the stoma well. Now you need to practice putting on the appliance.”
c.
“You seem to understand what I taught you today. What else can I help you with?”
d.
“You seem uncomfortable. Do you want your daughter to care for your ostomy?”
ANS: B
The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.
DIF: Applying/Application REF: 1179
A nurse assesses a client who is hospitalized for botulism. The client’s vital signs are temperature: 99.8° F (37.6° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take?
a.
Decrease stimulation and allow the client to rest.
b.
Stay with the client while another nurse calls the provider.
c.
Increase the client’s intravenous fluid replacement rate.
d.
Check the client’s blood glucose and administer orange juice.
ANS: B
A client with botulism is at risk for respiratory failure. This client’s respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the client’s blood glucose and administering orange juice are not appropriate actions.
DIF: Applying/Application REF: 1191
