Final exam - Flashcards
The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?
“Iron supplements will give me diarrhea.”
“Meat does not provide iron and should be avoided.”
“The iron is best absorbed if taken on an empty stomach.”
“On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement.”
“The iron is best absorbed if taken on an empty stomach.”
Rationale:
Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
Notify the surgeon.
Administer the prescribed pain medication.
Call and ask the operating room team to perform surgery as soon as possible.
Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
Notify the surgeon.
Rationale:
On the basis of the signs and symptoms presented in the question, the nurse would suspect peritonitis and notify the surgeon. Administering pain medication is not an appropriate intervention. Heat would never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the surgeon probably would perform the surgery earlier than the prescheduled time.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.
Diarrhea
Black, tarry stools
Hyperactive bowel sounds
Gray-blue color at the flank
Abdominal guarding and tenderness
Left upper quadrant pain with radiation to the back
Gray-blue color at the flank
Abdominal guarding and tenderness
Left upper quadrant pain with radiation to the back
Rationale:
Grayish-blue discoloration at the flank is known as Grey Turner’s sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.
Fever
Positive Cullen’s sign
Complaints of indigestion
Palpable mass in the left upper quadrant
Pain in the upper right quadrant after a fatty meal
Vague lower right quadrant abdominal discomfort
Fever
Complaints of indigestion
Pain in the upper right quadrant after a fatty meal
Rationale:
During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen’s sign) is associated with pancreatitis.
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
Malaise
Dark stools
Weight gain
Left upper quadrant discomfort
Malaise
Rationale:
Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.
Maintain NPO (nothing by mouth) status.
Encourage coughing and deep breathing.
Give small, frequent high-calorie feedings.
Maintain the client in a supine and flat position.
Give hydromorphone intravenously as prescribed for pain.
Maintain intravenous fluids at 10 mL/hour to keep the vein open.
Maintain NPO (nothing by mouth) status.
Encourage coughing and deep breathing.
Give hydromorphone intravenously as prescribed for pain.
Rationale:
The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn’s disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?
“I need to increase fiber in my diet every day.”
“I will need to avoid caffeinated beverages.”
“I’m going to learn some stress reduction techniques.”
“I can have exacerbations and remissions with Crohn’s disease.”
“I need to increase fiber in my diet every day.”
Rationale:
Crohn’s disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which sign(s)/symptom(s) of duodenal ulcer?
Weight loss
Nausea and vomiting
Pain relieved by food intake
Pain radiating down the right arm
Pain relieved by food intake
Rationale:
A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or “hungry” pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
The nurse is providing care for a client with a recent transverse colostomy created to resolve a bowel obstruction. Which observation requires immediate notification of the primary health care provider?
Stoma is beefy red and shiny
Purple discoloration of the stoma
Skin excoriation around the stoma
Semi-formed stool noted in the ostomy pouch
Purple discoloration of the stoma
Rationale:
Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.
A client has just had surgery to create an ileostomy for treatment of a bowel obstruction. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery?
Folate deficiency
Malabsorption of fat
Intestinal obstruction
Fluid and electrolyte imbalance
Fluid and electrolyte imbalance
Rationale:
A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?
Sweating and pallor
Bradycardia and indigestion
Double vision and chest pain
Abdominal cramping and pain
Sweating and pallor
Rationale:
Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication?
Stroke
Pernicious anemia
Bacterial meningitis
Peripheral arterial disease
Pernicious anemia
Rationale:
Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.
A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching?
“I eat at least 3 large meals each day.”
“I eat while lying in a semirecumbent position.”
“I have eliminated taking liquids with my meals.”
“I eat a high-protein, low- to moderate-carbohydrate diet.”
“I eat at least 3 large meals each day.”
Rationale:
Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals.
The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD?
Recently retired from a job
Significant other has a gastric ulcer
Occasionally drinks 1 cup of coffee in the morning
Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis
Takes nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis
Rationale:
Risk factors for PUD include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, NSAIDs, caffeine, alcohol, and stress. When an NSAID is taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn’s disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for PUD by changing the amount of gastric and biliary acids produced. Recent retirement should decrease stress levels rather than increase them. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. A significant other is not a first-degree relative; therefore, no genetic connection is noted in this relationship. Although caffeinated drinks are a known risk factor for PUD, the option states that the client drinks 1 cup of coffee occasionally.
The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful?
Fresh fruit
Brown gravy
Fresh vegetables
Poultry without skin
Brown gravy
Rationale:
The client with cholecystitis would decrease overall intake of dietary fat. Foods that need to be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.
