EAQ #3 Flashcards
The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching?
“Before I start the procedure, I will don sterile gloves.”
“Before I start the procedure, I will obtain my body weight.”
“Before I start the procedure, I will measure the residual volume.”
“Before I start the procedure, I will instill 1 oz [30 mL] of a carbonated liquid.”
“Before I start the procedure, I will measure the residual volume.”
Measuring the residual volume establishes the absorption amount of the previous feeding. If a residual exceeds the parameter identified by the health care provider or is over 200 mL, a feeding may be held. This safety measure prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. The client obtains and reports weekly or monthly weights, depending on the client’s condition and clinical goals. If the tube becomes clogged, the client may instill 30 mL of a carbonated beverage; this action is not used routinely.
After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client’s jaundice?
Necrosis of the parenchyma caused by the neoplasm
Excessive serum bilirubin caused by red blood cell destruction
Obstruction of the common bile duct by the pancreatic neoplasm
Impaired liver function, resulting in incomplete bilirubin metabolism
Obstruction of the common bile duct by the pancreatic neoplasm
The common bile duct passes through the head of the pancreas; the neoplasm often constricts or obstructs the duct, causing jaundice. Necrosis of the pancreatic parenchyma caused by the neoplasm will not cause jaundice. Excessive serum bilirubin caused by red blood cell destruction is the prehepatic cause of jaundice. Impaired liver function, resulting in incomplete bilirubin metabolism, is a hepatic cause of jaundice.
Which nutrient is broken down into glucose, fructose, and galactose?
Lipids
Proteins
Vitamins
Carbohydrates
Carbohydrates
A client expresses a complete lack of interest in food. How would the nurse document this finding in the client’s medical record?
Apathy
Aphasia
Adactyly
Anorexia
Anorexia
Adactyly refers to the absence of digits on:
the hands or feet.
Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma?
Dry, pale pink, and even with the skin
Moist, skin-colored, and flush with the skin
Moist, red, and raised above the skin surface
Dry, purple, and depressed below the skin surface
Moist, red, and raised above the skin surface
Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer?
The pain intensifies after vomiting stomach contents.
The pain occurs 1 to 2 hours after having a meal.
The pain increases when ingesting an excess of fatty foods.
The pain begins in the epigastrium and radiates to the abdomen.
The pain occurs 1 to 2 hours after having a meal.
The nurse identifies which weight category as reflective of a client’s body mass index (BMI) of 25.5 kg/m 2?
Obese
Normal
Overweight
Underweight
Overweight
A BMI between 25 and 29.9 kg/m 2 places the client in the overweight category. A BMI of 30 kg/m 2 is considered obese. A normal BMI is between 18.5 kg/m 2 and 24.9 kg/m 2. A BMI below 18.5 kg/m 2 is considered underweight.
A BMI between 25 and 29.9 kg/m 2 places the client in the ___________ category
overweight
A BMI of 30 kg/m 2 is considered ________.
obese
A normal BMI is between:
18.5 kg/m 2 and 24.9 kg/m 2.
A BMI below 18.5 kg/m 2 is considered ___________.
underweight
Which assessment parameter is used to determine the severity of blood loss in a client with an upper gastrointestinal (UGI) bleed? Select all that apply. One, some, or all responses may be correct.
Hematocrit
Hemoglobin
Platelet count
Oxygen saturation
Blood urea nitrogen (BUN)
all of the above
Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct.
Tachycardia
Hypotension
Rigid abdomen
Nausea and vomiting
Back and shoulder pain
All of the above
Which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease?
Esophageal pain may imitate the symptoms of a heart attack.
GERD may predispose the client to the development of heart disease.
Strenuous exercise may exacerbate reflux problems.
Similar laboratory study changes may occur in both problems.
Esophageal pain may imitate the symptoms of a heart attack.
When admitting an older client, the stool specimen confirmed a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse inquires about potentially assigning Room 2010, Bed B, the same isolation room as another client (2010, Bed A) who has MRSA. Which response would the nurse receive?
“The other client’s infection is not contagious.”
“This is the usual practice when antibiotic therapy is started.”
“Placing clients with the same infection in 1 room is safe.”
“As soon as a private room becomes available, we will move the client.”
“Placing clients with the same infection in 1 room is safe.”
A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change?
Stimulation of the liver to produce an excess quantity of bile pigments
Inability of the liver to remove normal amounts of bilirubin from the blood
Increased destruction of red blood cells during the acute phase of the disease
Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
Inability of the liver to remove normal amounts of bilirubin from the blood
A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. Which explanation would the nurse give?
Stores and concentrates bile
Releases bile into the pancreatic duct
Connects the common bile duct and the pancreas
Controls the flow of fat through the sphincter of Oddi
Stores and concentrates bile
The sphincter of Oddi controls the release of ______ into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.
bile
A client with a body mass index (BMI) of 35 verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by making which dietary change?
Decrease portion size and fat intake.
Increase protein and vegetable intake.
Decrease carbohydrate and fat intake.
Increase fruits and limit fluid intake.
Decrease portion size and fat intake.
A client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing this client for risk factors?
Men are more likely to be affected than women.
Young people are affected more frequently than older people.
Individuals who are obese are more prone to this condition than those who are thin.
People who are physically active are more apt to develop this condition than those who are sedentary.
Individuals who are obese are more prone to this condition than those who are thin.
Cholelithiasis occurs more frequently in individuals who are _______ and have hyperlipidemia.
Women are more likely to develop cholelithiasis. Middle-aged people, usually over 40 years, are more likely to develop this condition than younger people; aging increases risk. People who have sedentary lifestyles are more likely to develop this condition than those who are active.
obese
A client with a high cholesterol level says to the nurse, “Why can’t I take a medication that will eliminate all of the cholesterol in my body so it isn’t a problem?” The nurse explains that some cholesterol is needed to perform which body function?
Blood clotting
Bone formation
Muscle contraction
Cellular membrane structure
Cellular membrane structure
_____________ is an essential structural and functional component of most cellular membranes.
Cholesterol
A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate?
No protein
Moderate protein
High protein
Strict protein restriction
Moderate protein
Because the liver is unable to detoxify ammonia to urea and the client is experiencing clinical manifestations leading to an impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no-protein restrictions are not required because the client needs protein for healing. The hepatic encephalopathy diagnosis contradicts high-protein intake because protein breaks down into ammonia.
Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis?
Turkey salad, French fries, sherbet
Cottage cheese, mixed fruit salad, milkshake
Salad, sliced chicken sandwich, gelatin dessert
Cheeseburger, tortilla chips, chocolate pudding
Salad, sliced chicken sandwich, gelatin dessert
The viral hepatitis diet should be high in carbohydrates, with moderate protein and fat content. A salad, chicken, and gelatin meal is the best choice. Turkey salad, French fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the hepatitis virus injures the intestinal mucosa and reduces the client’s ability to metabolize lactose. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.
The viral hepatitis diet should be high in ____________ , with moderate protein and fat content.
carbohydrates
On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client’s abdomen and determines rigidity. Which action would the nurse perform first?
Assist the client to ambulate.
Obtain the client’s vital signs.
Administer the prescribed analgesic.
Encourage use of the incentive spirometer.
Obtain the client’s vital signs.
Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; vital signs provide supporting data. The nurse assists the client to ambulate if pain was the result of flatulence; however, rigidity is associated with bleeding or peritonitis, and the nurse needs additional data. An analgesic may mask the symptoms, thereby delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to the symptoms presented.
The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis?
Fever and malaise
Nausea and vomiting
Absolute constipation
Pain in right lower quadrant
Pain in right lower quadrant
Pain shifting to the right lower quadrant between the anterior iliac crest and the umbilicus is McBurney point and is indicative of appendicitis. The client may also have fever, nausea, and vomiting, but these can occur with other infectious processes. Absolute constipation occurs with many bowel obstructions.
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct.
Diarrhea
Bradycardia
Rebound tenderness
Diminished bowel sounds
Rigid, boardlike abdomen
Rebound tenderness
Diminished bowel sounds
Rigid, boardlike abdomen
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause?
Gastritis
Hiatal hernia
Diverticulosis
Bowel obstruction
Bowel obstruction
Causes of peritonitis include bowel obstruction, appendicitis, external penetrating wound, or peritoneal dialysis. Gastritis and hiatal hernias do cause gastrointestinal discomfort, but not peritonitis. Inflammation of the diverticular pockets, diverticulitis, is a cause of peritonitis. Diverticulosis is not an active inflammatory process.
Which information would the nurse provide a client with a new colostomy about managing the appliance?
Use stoma powder for fungal rashes.
Wash peristomal area with soap first.
Measure stoma once a month for size.
Cut opening 1/8- to 1/16-inch larger than stoma.
Cut opening 1/8- to 1/16-inch larger than stoma.
The first 6 to 8 weeks after surgery as inflammation subsides, the stoma will shrink in size. Therefore it is important to measure the stoma once a week and cut the opening 1/8- to 1/16-inch larger than the stoma so the wafer does not cut into the stoma. Antifungal cream or powder is used for fungal rashes. Soap should not be used on the peristomal area to prevent drying, which can lead to infection.
The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select?
Levin
Dobhoff
Salem sump
Gastrostomy
Salem sump
A Salem sump tube has a vent that prevents the suction from pulling at the gastrointestinal mucosa and should be used for clients requiring continuous suction. A Levin tube does not have a vent and should be used strictly for intermittent suction. A Dobhoff is a nasointestinal tube used for feeding, not suction. A gastrostomy tube is surgically placed for feeding.
During a health symposium the nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood?
“Meats and cream-based foods need to be refrigerated.”
“Once most food is cooked, it does not need to be refrigerated.”
“Poultry should be stuffed and then refrigerated before cooking.”
“Cooked food should be cooled before being put into the refrigerator.”
“Meats and cream-based foods need to be refrigerated.”
A cold environment limits growth of microorganisms. All food should be refrigerated before and after it is cooked to limit the growth of microorganisms. Stuffing and then refrigerating poultry promotes the growth of microorganisms because the stuffing will still be warm for a period before the refrigerator’s cold environment cools the center of the bird. It is advocated that poultry not be stuffed. If it is stuffed, it should be done immediately before cooking. Letting cooked foods cool before refrigeration promotes the growth of microorganisms because microorganisms thrive in warm, moist environments.
Which recommendation would the nurse provide to a client with gastroesophageal reflux disease (GERD) who asks how to reduce heartburn and pain without taking medication?
Chew hard mint candies.
Eat a small bedtime snack.
Elevate the head of the bed 5 inches.
Avoid white wine consumption.
Elevate the head of the bed 5 inches.
The nurse would instruct the client to elevate the head of the bed 4 to 6 inches as this prevents reflux of gastric contents into the esophagus. Mints, especially peppermint, weaken lower esophageal sphincter (LES) pressure and allow gastric contents to reflux. The client should refrain from eating 3 hours before bed as this also affects the LES pressure. Red wine weakens the LES pressure.
Which information to promote self-management would the nurse provide to a client being discharged with a new ileostomy?
Consume 1000 mL/day of fluid.
Limit alcohol to one or two glasses daily.
Include plenty of nuts and seeds in the diet.
Change the appliance every 4 to 7 days.
Change the appliance every 4 to 7 days.
A client with an ileostomy should be instructed to change the appliance every 4 to 7 days and cleanse the skin to prevent irritation when changing. Clients should be advised to drink at least 3000 mL of fluid in a 24-hour period and even more when the weather is hot. Clients should avoid alcohol of any kind because it can cause diarrhea. Nuts and seeds can become trapped in the bowel and should be avoided.
Which finding indicates that a client is at an increased risk for colorectal cancer (CRC)? Select all that apply. One, some, or all responses may be correct.
Presence of dark, tarry stools
Family history of polyposis
20-year history of ulcerative colitis
Unintentional 20-pound weight loss
Change in bowel pattern for 3 months
all of the above
Which factor can be used to determine the source of infection in a client who tests positive for Giardia lamblia?
Sexual orientation
Past antibiotic use
Recent camping trips
Raw egg consumption
Recent camping trips
Giardia is found in freshwater lakes and rivers. Clients who test positive for the bacteria should be asked about recent travel and activity history including outings like camping or hiking. Giardiasis is associated with anal intercourse regardless of sexual orientation. Antibiotic use can cause Clostridium difficile infection. Raw eggs can carry Salmonella.
The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step?
Wait until a family member is present.
Assess barriers to learning colostomy care.
Provide simple written instructions concerning the care.
Wait until the client has accepted the change in body image.
Assess barriers to learning colostomy care.
Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Beginning with simple written instructions concerning the care is premature. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. Waiting until the client has accepted the change in body image may be an unrealistic expectation; the client may never accept the change but must learn to manage care.
A client is admitted to the hospital with a diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client?
Controlling constipation
Meeting nutritional needs
Preventing increased weakness
Anticipating a sexual alteration
Meeting nutritional needs
To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.
A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, which would the nurse emphasize?
Medical treatment is curative; surgery is not required.
For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful.
For most clients, surgery is recommended early in the course of treatment.
Medical treatment is all that will be needed if the client can maintain emotional stability.
For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful.
Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. Stating that medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.
