Unit O-Clients with Non-Inflammatory/Inflammatory Intestinal Disease (GI)

Question 1

The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have?

a. Steatorrhea
b. Ulcerative colitis
c. Crohn disease
d. Lactose intolerance

Answer 1

ANS: D
The client is demonstrating signs and symptoms of lactose intolerance because they occur after the client eats or drinks dairy products which contain lactose.

Question 2

The primary health care provider documents that a client has a bruit over the abdominal aorta. What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding?
a. “Use warm compresses on the client’s abdomen continuously.”
b. “Avoid washing the client’s abdomen too aggressively.”
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c. “Apply ice to the client’s abdomen every 4 hours.” d. “Massage the client’s abdomen to help reduce pain.”

Answer 2

ANS: B
A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which should not be palpated or percussed. Therefore, the AP should wash the client’s abdomen very gently.

Question 3

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client’s respiratory rate is 8 breaths/min. What action by the nurse is appropriate?

a. Administer naloxone.
b. Call the Rapid Response Team.
c. Provide physical stimulation.
d. Ventilate with a bag-valve-mask.

Answer 3

ANS:C
For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse’s most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation

Question 4

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?

a. “It’s a good thing I love orange and cherry gelatin.”
b. “My spouse will be here to drive me home.”
c. “I’ll avoid ibuprofen for several days before the test.”
d. “I’ll buy a case of clear Gatorade before the prep.”

Answer 4

ANS: A
The client would be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show an understanding of the preparation for the procedure.

Question 5

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report
a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate?
a. Ask the client to call back if this happens again today.
b. Instruct the client to go to the emergency department.
c. Remind the client that a small amount of bleeding is possible.
d. Tell the client to come to the clinic this afternoon.

Answer 5

ANS: C
After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

Question 6

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best?

a. “Changes in your liver cause drugs to be metabolized differently.”
b. “Perhaps you don’t need as high a dose of the drug as before.”
c. “Stomach muscles atrophy with age and you digest more slowly.”
d. “Your body probably can’t tolerate as much medication anymore.”

Answer 6

ANS:A
Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change

Question 7

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client?

a. Left lateral
b. Prone
c. Right lateral
d. Supine

Answer 7

ANS: A

After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

Question 8

A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client’s abdomen?

a. Auscultate after palpating.
b. Avoid any type of palpation
c. Lightly palpate the RUQ first.
d. Lightly palpate the RUQ last.

Answer 8

ANS: D
If pain is present in a certain area of the abdomen, that area would be palpated last to keep the client from tensing which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

Question 9

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?

a. Kidneys
b. Liver
c. Spleen d. Stomach

Answer 9

ANS: B
Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

Question 10

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate?

a. Allow the client cool liquids only.
b. Assess the client’s gag reflex.
c. Remind the client to remain NPO.
d. Tell the client to wait 4 hours.

Answer 10

ANS: B
The local anesthetic used during this procedure depresses the client’s gag reflex. After the procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client’s readiness for them.

Question 11

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client?

a. Culture and sensitivity
b. Parasites and ova
c. Occult blood test d. Total fat content

Answer 11

ANS: C
Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood test would be the most appropriate test as a follow-up.

Question 12

The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.)

a. Colonoscopy every 10 years
b. Endoscopy every 5 years
c. Computed tomography (CT) colonography every 5 years
d. Double-contrast barium enema every 10 years
e. Flexible sigmoidoscopy every 5 years

Answer 12

ANS:A,C,E
The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

Question 13

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.)

a. Cholangitis
b. Pancreatitis
c. Perforation
d. Renal lithiasis
e. Sepsis

Answer 13

ANS: A,B,C,E
Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

Question 14

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.)

a. Decreased hydrochloric acid production
b. Diminished sensation that can lead to constipation
c. Fat not digested as well in older adults
d. Increased peristalsis in theGlaRrgAeDinEteSstLinAeB.COM
e. Pancreatic vessels become calcified

Answer 14

ANS: A,B,C,E
Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

Question 15

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to which organ functions or dysfunctions? (Select all that apply.)

a. Alanine aminotransferase: biliary system
b. Ammonia: liver
c. Amylase: liver
d. Lipase: pancreas
e. Urine urobilinogen: stomach

Answer 15

ANS: B,D
Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

Question 16

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.)

a. Obtain vital signs every 15 to 30 minutes until alert.
b. Assess the client for rectal bleeding and severe pain.
c. Administer prescribed pain medications as needed.
d. Monitor the client’s serum and urine glucose levels.
e. Confirm the client has a ride home and plans to rest.

Answer 16

ANS: A,B,E
During the recovery phase after a colonoscopy, the nurse would obtain vital signs
every 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain, and confirm the client has arranged for another person to drive home to get rest. Pain medications are not necessary after the procedure, and neither is glucose monitoring.

Question 17

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

a. Ham sandwich on white bread, cup of applesauce, carbonated beverage
b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice
c. Grilled cheese sandwich, small banana, cup of hot tea with lemon
d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

Answer 17

ANS: B
Patients with IBS are advised to eat a high-fiber diet. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. Clients should avoid alcohol, caffeine, and other gastric irritants.

Question 18

A nurse assesses a client who is prescribed alosetron. Which assessment question would the nurse ask this client before starting the drug?

a. “Have you been experiencing any constipation?”
b. “Are you eating a diet high in fiber and fluids?”
c. “Do you have a history of high blood pressure?”
d. “What vitamins and supplements are you taking?”

Answer 18

ANS: A
Ischemic colitis is a life-threatening complication of alosetron. The nurse would assess the client for constipation because it places the client at risk for this complication. The other questions do not identify the risk for complications related to alosetron.

Question 19

The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk?

a. Abdominal distention
b. Nausea
c. Electrolyte imbalance
d. Obstipation

Answer 19

ANS: C
The client who has a small bowel obstruction is at the highest risk for fluid and electrolyte imbalances, especially dehydration and hypokalemia due to profuse vomiting. Nausea, abdominal distention, and obstipation are also usually present, but these problems are not as life threatening as the imbalances in electrolytes

Question 20

A nurse assesses clients at a community health center. Which client is at highest risk for developing colorectal cancer?

a. A 37-year-old who drinks eight cups of coffee daily.
b. A 44-year-old with irritable bowel syndrome (IBS).
c. A 60-year-old lawyer who works 65 hours per week.
d. A 72-year-old who eats fast food frequently.

Answer 20

ANS: D
Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

Question 21

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action would the nurse take?

a. Ask if the client is experiencing pain in the right shoulder.
b. Perform a rectal examination and assess for polyps.
c. Recommend that the client have computed tomography.
d. Administer a laxative to increase bowel movement activity.

Answer 21

ANS: C
The presence of visible peristaltic waves, accompanied by high-pitched or high-pitched bowel sounds, is indicative of bowel obstruction caused by the tumor. The nurse would contact the primary health care provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The nurse generalist is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

Question 22

The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction?

a. Alosetron
b. Alvimopan
c. Amitiptyline d. Amlodipine

Answer 22

ANS: B
Alvimopan is the appropriate drug to promote peristalsis for clients who have a paralytic ileus. The other drugs do not affect intestinal activity.

Question 23

A nurse cares for a client with colorectal cancer who has a new colostomy. The client states, “I think it would be helpful to talk with someone who has had a similar experience.” How would the nurse respond?

a. “I have a good friend with a colostomy who would be willing to talk with you.”
b. “The ostomy nurse will be able to answer all of your questions.”
c. “I will make a referral to the United Ostomy Associations of America.”
d. “You’ll find that most people with colostomies don’t want to talk about them.”

Answer 23

ANS: C
Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including ostomates (specially trained visitors who also have ostomies). The nurse would not suggest that the client speak with a personal contact of the nurse. Although the ostomy nurse is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse would not brush aside the client’s request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.

Question 24

The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed?

a. Prone
b. Supine
c. Recumbent
d. Semi-Fowler

Answer 24

ANS: D
Having the client in a semi-sitting position helps to decrease the pressure caused by abdominal distention and promotes thoracic expansion to facilitate breathing.

Question 25

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, “The stool in my pouch is still liquid.” How would the nurse respond? a. “The stool will always be liquid with this type of colostomy.” b. “Eating additional fiber will bulk up your stool and decrease diarrhea.” c. “Your stool will become firmer over the next couple of weeks.” d. “This is abnormal. I will contact your primary health care provider.”

Answer 25

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client’s diet or with the passage of time.

Question 26

A nurse teaches a client who is at risk for colorectal cancer. Which dietary recommendation would the nurse teach the client? a. “Eat low-fiber and low-residual foods.” b. “White rice and bread are easier to digest.” c. “Add vegetables such as broccoli and cauliflower to your diet.” d. “Foods high in animal fat help to protect the intestinal mucosa.”

Answer 26

ANS: C The client would be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

Question 27

A nurse cares for a client who has a new colostomy. Which action would the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and barrier every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

Answer 27

ANS: A The nurse would empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy barriers would be used to secure and seal the ostomy appliance; surgical tape would not be used.

Question 28

A nurse cares for a client who has a family history of colorectal cancer. The client states, “My father and my brother had colon cancer. What is the chance that I will get cancer?” How would the nurse respond? a. “If you eat a low-fat and low-fiber diet, your chances decrease significantly.” b. “You are safe. This is an autosomal dominant disorder that skips generations.” c. “Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer. ” d. “You should have a colonoscopy more frequently to identify abnormal polyps early. ”

Answer 28

ANS: D The nurse would encourage the patient to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client’s diet to more high-fiber (not low-fiber) and preemptive chemotherapy may decrease the client’s risk of colon cancer but will not prevent it.

Question 29

The nurse is caring for a client who is planning to have a laparoscopic colon resection for colorectal cancer tomorrow. Which statement by the client indicates a need for further teaching? a. “I should have less pain after this surgery compared to having a large incision.” b. “I will probably be in the hospital for 3 to 4 days after surgery.” c. “I will be able to walk around a little on the same day as the surgery.” d. “I will be able to return to work in a week or two depending on how I do.”

Answer 29

ANS:B All of these statements are correct about having minimally invasive laparoscopic surgery except that the hospital stay will likely be only 1 or 2 days

Question 30

The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug? a. “This drug will make you very dry because it will decrease your diarrhea.” b. “Be sure to take this drug with food and water to help manage constipation.” c. “Avoid people who have infection as this drug will suppress your immune system.” d. “Include high-fiber foods in your diet to help produce more solid stools.”

Answer 30

ANS: B Lubiprostone is an oral laxative approved for women who have IBS with constipation (IBS-C). Water and food will also help to improve constipation. The drug is not used for clients who have diarrhea and does not affect the immune system. Although high-fiber foods are important for clients who have IBS, this client does not need fiber to help make stool more solid. Instead the fiber will help prevent constipation.

Question 31

``` A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which complication would the nurse monitor? a. Paralytic ileus b. Bowel volvulus c. Sepsis d. Colitis ```

Answer 31

ANS: C The client who has a strangulated inguinal hernia would likely develop bowel necrosis which can lead to sepsis. The nurse would observe for early signs and symptoms of sepsis such as fever, tachypnea, and tachycardia. If the client’s condition is not promptly managed, bowel perforation, septic shock, and death can result.

Question 32

The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle change would the nurse include? a. Avoiding alcohol b. Quitting smoking c. Decreasing fluid intake d. Increasing dietary fiber

Answer 32

ANS:C The major cause of hemorrhoid formation is constipation. Therefore, the nurse teaches the client ways to prevent constipation, which include increasing dietary fiber, increasing exercise and fluid intake, and avoiding straining when have a stool.

Question 33

The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would the nurse expect? (Select all that apply.) a. Weight gain b. Rectal bleeding c. Anemia d. Change in stool shape e. Electrolyte imbalances f. Abdominal discomfort

Answer 33

ANS: B,C,D,F The client who has CRC usually experiences unintentional weight loss and rectal bleeding, either gross or occult. As a result of bleeding, the client has anemia and fatigue. Electrolyte imbalances are not common, but the client may note that the shape or consistency of stool has changed.

Question 34

After teaching a client who is recovering from a colon resection to treat early-stage colorectal cancer (CRC), the nurse assesses the client’s understanding. Which statements by the client indicate understanding of the teaching? (Select all that apply.) a. “I must change the ostomy appliance daily and as needed.” b. “I will use warm water and a soft washcloth to clean around the stoma.” c. “I might start bicycling and swimming again once my incision has healed.” d. “I will make sure that I make lifestyle changes to prevent constipation.” e. “I will be sure to have the recommended colonoscopies.”

Answer 34

ANS: C,D,E The client has had a colon resection for early CRC and there is no indication that the client also had a colostomy. Follow up with recommended colonoscopies are essential to monitor for CRC recurrence. Avoiding constipation will help improve intestinal motility which helps to decrease the risk for CRC recurrence. Exercise and other activities do not need to be restricted after the client has healed.

Question 35

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client’s assessment? (Select all that apply.) a. “Which food types cause an exacerbation of symptoms?” b. “Where is your pain or discomfort and what does it feel like?” c. “Have you lost a significant amount of weight lately?” d. “Are your stools soft, watery, and black?” e. “Do you often experience nausea and vomiting”

Answer 35

ANS: A,B The nurse would ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse would also assess the location, intensity, and quality of the patient’s pain or discomfort. Clients who have IBS do not usually lose weight, have nausea and vomiting, or have stools that are black

Question 36

A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L (2.8 mmol/L) b. Loss of 15 lb (6.8 kg) without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L (121 mmol/L)

Answer 36

ANS: A,C,E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]) and hyponatremic ). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.

Question 37

The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the nurse take for client care? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours or per agency policy. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client’s chin. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client’s skin around the tube site for irritation.

Answer 37

ANS: A,D,E The nurse would frequently assess for NGT placement, patency, and output (drainage) every 4 hours or per agency policy. The nurse would also monitor the skin around the tube for irritation and secure the tube to the client’s nose. When auscultating bowel sounds for peristalsis, the nurse would disconnect suction. NGT irrigation may or may not be prescribed. If it is prescribed, hourly irrigation is not appropriate.

Question 38

The nurse is caring for a client who has perineal surgical wound. Which actions would the nurse take to promote comfort and wound healing? (Select all that apply.) a. Assist the client into a side-lying position. b. Use a rubber donut device when sitting up. c. Apply warm compresses three to four times a day. d. Instruct the client to wear boxer shorts. e. Place an absorbent dressing over the wound.

Answer 38

ANS: A,C,E The nurse would place an absorbent pad over the wound and apply warm compresses to the wound area. The nurse would also instruct the male client to wear jockey-type shorts for support rather than boxers, assume a side-lying position in bed, avoid sitting for long periods, and use foam pads or soft pillows whenever in a sitting position. The patient should avoid the use of air rings or rubber donut devices.

Question 39

The nurse is caring for a client who just had a minimally invasive inguinal hernia repair. Which nursing actions would the nurse implement? (Select all that apply.) a. Apply ice to the surgical area for the first 24 hours after surgery. b. Encourage ambulation with assistance within the first few hours after surgery. c. Encourage deep breathing after surgery but teach the client to avoid coughing. d. Assess vital signs frequently for the first few hours after surgery. e. Teach the client to rest for several days after surgery when at home. f. Teach the client not to lift more than 10 lb (4.5 kg) until allowed by the surgeon.

Answer 39

ANS: A,B,C,D,E,F | All of these nursing actions are appropriate for the client having MIS for inguinal hernia repair.

Question 40

The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) a. Stool consistency is similar to paste. b. Stoma becomes dark and dull. c. Skin around the stoma becomes excoriated. d. Skin around stoma becomes protruded. e. Stoma becomes retracted into the abdomen

Answer 40

ANS: B,C,D,E A colostomy placed in the descending colon would be expect to have a paste-like stool consistency. However, if the stoma becomes retracted or discolored, the client should report those changes to the primary health care provider. Skin around the stoma that becomes protruded would suggest the formation of a peristomal hernia, and skin excoriation needs appropriate management. Therefore, both of those skin changes would need to be reported to the primary health care provider.

Question 41

The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? 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

Answer 41

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.

Question 42

The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? a. Decreased potassium level b. Increased sodium level c. Elevated leukocyte count d. Decreased thrombocyte count

Answer 42

ANS: C Appendicitis is an acute inflammatory disorder that frequently results in elevation of leukocytes (white blood cells). Serum electrolytes are not affected because the client does not usually have diarrhea. Thrombocyte (platelet) count is unrelated to this GI disorder.

Question 43

The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? a. “Drink plenty of fluids to prevent dehydration.” b. “You should only drink 1 L of fluids daily.” c. “Increase your protein intake by drinking more milk.” d. “Sips of cola or tea may help to relieve your nausea.”

Answer 43

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.

Question 44

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? a. Consuming too much fruit b. Consuming fried or pickled foods c. Consuming dairy products d. Consuming raw seafood

Answer 44

ANS: D Raw seafood is often contaminated and unless cooked can would most likely cause gastroenteritis. Any of the other food can also become contaminated if not stored properly or contaminated by workers/cooks who contaminate these foods.

Question 45

The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? a. Positive Murphy 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

Answer 45

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn disease. A positive Murphy sign is indicative of gallbladder disease, and rebound tenderness often indicates peritGonRiAtisD.EDSulLlnAesBs.inCtOheMlower abdominal quadrants and hypoactive bowel sounds is not commonly found with Crohn disease. Nightly worsening of abdominal cramping is not consistent with Crohn disease.

Question 46

After teaching a patient with diverticular disease, a nurse assesses the client’s understanding. Which menu selection 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

Answer 46

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 [240 mL] of bean soup) would 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.

Question 47

A nurse cares for a young client with a new ileostomy. The client states, “I cannot go to prom with an ostomy.” How would 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 ostomy nurse 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.”

Answer 47

ANS: C The ostomy nurse is a valuable resource for patients, 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.

Question 48

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? a. “I won’t let anyone use my dishes or glasses.” b. “I’ll wash my hands with antibacterial soap.” c. “I’ll keep my bathroom extra clean.” d. “I’ll cook all the meals for my family.”

Answer 48

ANS: D All of these statements are correct except for that the client should not prepare meals for others to help prevent transmission of gastroenteritis.

Question 49

After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client’s understanding. Which statement made by the client indicates a need for further 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 should wash my hands after I play with my dog.”

Answer 49

ANS: B Adalimumab is an immune modulator that is 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.

Question 50

The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug? a. “Are you taking Vitamin C or B? b. “Do you have any allergy to sulfa drugs?” c. “Can you swallow pills pretty easily?” d. “Do you have insurance to cover this drug?”

Answer 50

ANS: B Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should not be given to those who have an allergy to sulfa and sulfa drugs to prevent a hypersensitivity reaction.

Question 51

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

Answer 51

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 would 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 patient than heart rate and rhythm.

Question 52

A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include? a. “You will have to wear an appliance for your permanent ileostomy.” b. “You should be able to have better bowel continence after healing occurs.” c. “You will have a large abdominal incision that will require irrigation.” d. “This procedure can be performed under general or regional anesthesia.”

Answer 52

ANS: B A RCA-IPAA can improve bowel continence although leakage may still occur for some clients. The procedure is a 2-step process performed under general anesthesia using a laparoscope which does not require an abdominal incision or permanent ileostomy.

Question 53

After teaching a client who has diverticulitis, a nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching? a. “I’ll ride my bike or take a long walk at least three times a week.” b. “I must try to include at least 25 g of fiber in my diet every day.” c. “I will take a laxative nightly at bedtime to avoid becoming constipated.” d. “I should use my legs rather than my back muscles when I lift heavy objects.”

Answer 53

ANS: C Laxatives are not recommended for patients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

Question 54

The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse’s priority action? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

Answer 54

ANS: B Protecting the client’s skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn disease also includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

Question 55

The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-tinged output

Answer 55

ANS: A The nurse would assess the stoma for color and contact the primary health care provider if the stoma is pale, bluish, or dark because these changes indicate possible lack of perfusion. The nurse would expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

Question 56

A nurse cares for a client with a new ileostomy. The client states, “I don’t think my friends will accept me with this ostomy.” How would the nurse respond? a. “Your friends will be happy that you are alive.” b. “Tell me more about your concerns.” c. “A therapist can help you resolve your concerns.” d. “With time you will accept your new body.”

Answer 56

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse would encourage the client to discuss concerns by restating them in an open-ended manner. The nurse would not minimize the client’s concerns or provide false reassurance.

Question 57

The nurse teaches a community group ways to prevent Escherichia coli infection. Which statements would the nurse include in this group’s teaching? (Select all that apply.) a. “Wash your hands after any contact with animals.” b. “It is not necessary to buy a meat thermometer.” c. “Stay away from people who are ill with diarrhea.” d. “Use separate cutting boards for meat and vegetables.” e. “Avoid swimming in backyard pools and using hot tubs.”

Answer 57

ANS: A,D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.

Question 58

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer e. Fistula—dilation and colonic ileus caused by paralysis of the colon

Answer 58

ANS: A,B,D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

Question 59

``` A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.) a. Weight gain b. Anorexia c. Constipation d. Anal fistula e. Abdominal pain ```

Answer 59

ANS: B,C,E Signs and symptoms of celiac disease include weight loss, anorexia, constipation, and abdominal pain. Anal fistulas are not associated with celiac disease.

Question 60

A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client’s plan of care? (Select all that apply.) a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. d. Provide the client with a high-fiber diet. e. Evaluate stools for occult blood.

Answer 60

ANS: A,B,C,E When caring for an older adult who has diverticulitis, the nurse would administer analgesics as prescribed, palpate the abdomen for distention and tenderness, assess for confusion and sudden changes in mental status, and check stools for occult or frank bleeding. A low-fiber/residue diet would be provided when symptoms are present and a high-fiber diet when inflammation resolves.

Question 61

A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? d. Do you have a scale for daily weights? e. How many bathrooms are in your home?

Answer 61

ANS: A,B,C,E A home assessment for a client who has a chronic inflammatory bowel disease would include identifying adequacy and availability of bathroom facilities, opportunities for rest and relaxation, and the client’s knowledge of dietary therapy, and when to contact the primary health care provider. The client does not need to perform daily weights.

Question 62

After teaching a patient who has a permanent ileostomy, a nurse assesses the client’s understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.) a. Corn b. String beans c. Carrots d. Wheat rice e. Squash

Answer 62

ANS: A,B,D Clients with an ileostomy should be cautious of high-fiber and high-cellulose foods including corn, string beans, and rice. Carrots and squash are low-fiber items

Question 63

A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) a. Cleanse the perineum with an antibacterial soap. b. Use medicated wipes instead of toilet paper. c. Identify foods that decrease constipation. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

Answer 63

ANS: B,D,E To prevent skin excoriation from frequent bowel movements associated with inflammatory bowel disease, the nurse would encourage good skin care with a mild soap and water and gently patting the area dry after each bowel movement. Using medicated wipes instead of toilet paper and applying a thin coat of aloe cream are appropriate. The client should identify and avoid foods that increase diarrhea. Antibacterial soaps are harsh and should not be used.

Question 64

The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.) a. Need to have drug administered by a primary health care provider. b. Need to avoid crowds and individuals who have infection. c. Need to report injection reactions such as redness and swelling. d. Awareness of a rare but potentially fatal drug complication. e. Need to report any signs and symptoms of infection immediately.

Answer 64

ANS: A,B,D,E All of these choices are correct except that the drug is given intravenously. Therefore, there is no need to teach the client to report injection reactions because the client does not self-administer the medication subcutaneously. Natalizumab can cause progressive multifocal leukoencephalopathy (PML), bGuRt iAt iDsEaSveLryABra.reCdOisMorder causing cognitive, sensory, and/or motor changes.

Question 65

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever

Answer 65

ANS: A,C,D,E,F Peritonitis is an acute inflammatory disorder. Therefore, the client would likely have all of these signs and symptoms but would have tachycardia rather than bradycardia due to dehydration from fever.

Question 66

Nurses must be alert for increased fluid requirements when a child presents with which possible concern? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure (ICP)

Answer 66

ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. ICP does not lead to increased fluid requirements in children.

Question 67

Which type of dehydration results from water loss in excess of electrolyte loss? a. Isotonic dehydration b. Isosmotic dehydration c. Hypotonic dehydration d. Hypertonic dehydration

Answer 67

ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Isosmotic dehydration is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.

Question 68

An infant is brought to the emergency department with poor skin turgor, sunken fontanel, lethargy, and tachycardia. This is suggestive of which condition? a. Overhydration b. Dehydration c. Sodium excess d. Calcium excess

Answer 68

ANS: B These clinical manifestations indicate dehydration. Symptoms of overhydration are edema and weight gain. Regardless of extracellular sodium levels, total body sodium is usually depleted in dehydration. Symptoms of hypocalcemia are a result of neuromuscular irritability and manifest as jitteriness, tetany, tremors, and muscle twitching.

Question 69

What is a common cause of acute diarrhea? a. Hirschsprung’s disease b. Antibiotic therapy c. Hypothyroidism d. Meconium ileus

Answer 69

ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Hirschsprung’s disease, hypothyroidism, and meconium ileus are usually manifested with constipation rather than diarrhea.

Question 70

The viral pathogen that frequently causes acute diarrhea in young children is: a. Giardia organisms. b. Shigella organisms. c. Rotavirus. d. Salmonella organisms.

Answer 70

ANS: C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United StNaUteRsS.

Question 71

A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which condition? a. Protein intolerance b. Parasitic infection c. Fat malabsorption d. Bacterial gastroenteritis

Answer 71

ANS: D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance is suspected in the presence of eosinophils. Parasitic infection is indicated by eosinophils. Fat malabsorption is indicated by foul-smelling, greasy, bulky stools.

Question 72

Therapeutic management of the child with acute diarrhea and dehydration usually begins with what intervention? a. Clear liquids b. Adsorbents such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric

Answer 72

ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended and neither are antidiarrheal because they do not get rid of pathogens.

Question 73

A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with which intervention? a. Intravenous fluids b. Oral rehydration solution (ORS) c. Clear liquids, 1 to 2 ounces at a time d. Administration of antidiarrheal medication

Answer 73

ANS: A Intravenous fluids are initiated in children with severe dehydration. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

Question 74

Constipation has recently becomeNaUpRrSoIbNlGemTBf.oCrOaMschool-age child who is being treated for seasonal allergies. The nurse should focus the assessment on what possibly related factor? a. Diet b. Allergies c. Antihistamines d. Emotional factors

Answer 74

ANS: C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known recent change in her habits, the addition of antihistamines is most likely the etiology of the diarrhea, rather than diet, allergies, or emotional factors. With a change in bowel habits, the presence and role of any recently prescribed medications should be assessed.

Question 75

Therapeutic management of most children with Hirschsprung’s disease is primarily: a. daily enemas. b. low-fiber diet. c. permanent colostomy. d. surgical removal of affected section of bowel.

Answer 75

ANS:D Most children with Hirschsprung’s disease require surgical rather than medical management. Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet until the child is physically ready for surgery. The colostomy that is created in Hirschsprung’s disease is usually temporary.

Question 76

A 4-month-old infant diagnosed with gastroesophageal reflux disease (GERD) is thriving without other complications. What should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

Answer 76

ANS: B Giving small frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk thickening agents have been shown to decrease the number of episodes of vomiting and increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive. Smaller, more frequent feedings are recommended in reflux.

Question 77

What is the primary purpose of prescribing a histamine receptor antagonist for an infant diagnosed with gastroesophageal reflux? a. Prevent reflux b. Prevent hematemesis. c. Reduce gastric acid production. d. Increase gastric acid production.

Answer 77

ANS: C The mechanism of action of histamine receptor antagonists is to reduce the amount of acid present in gastric contents and may prevent esophagitis. None of the remaining options are modes of action of histamine receptor antagonists but rather desired effects of medication therapy.

Question 78

Which clinical manifestation would most suggest acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney point

Answer 78

ANS:D Pain is the cardinal feature. It is initially generalized and usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Abdominal pain that is relieved by eating and bright or dark red rectal bleeding are not signs of acute appendicitis.

Question 79

When caring for a child with probable appendicitis, the nurse should be alert to recognize what sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distention

Answer 79

ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

Question 80

Which statement is most descriptive of Meckel’s diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.

Answer 80

ANS: C Blood stools are often a presenting sign of Meckel’s diverticulum. It is associated with mild-to-profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel’s diverticulum is the most common congenital malformation of the gastrointestinal tract and is present in 2% of the general population. The standard therapy is surgical removal of the diverticulum.

Question 81

What condition is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohn’s disease b. Ulcerative colitis c. Meckel’s diverticulum d. Irritable bowel syndrome

Answer 81

ANS: A The chronic inflammatory process of Crohn’s disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Ulcerative colitis, Meckel’s diverticulum, and irritable bowel syndrome do not affect the entire GI tract.

Question 82

What is used to treat moderate-to-severe inflammatory bowel disease? a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications

Answer 82

ANS: C Corticosteroids such as prednisone and prednisolone are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheals are not drugs of choice to treat the inflammatory process of inflammatory bowel disease. Antibiotics may be used as adjunctive therapy to treat complications.

Question 83

Bismuth subsalicylate may be prescribed for a child with a peptic ulcer to effect what result? a. Eradicate Helicobacter pylori b. Coat gastric mucosa c. Treat epigastric pain d. Reduce gastric acid production

Answer 83

ANS: A This combination of drug therapy is effective in the treatment and eradication of H. pylori. It does not bring about any of the results.

Question 84

The best chance of survival for a child with cirrhosis is: a. liver transplantation. b. treatment with corticosteroids. c. treatment with immune globulin. d. provision of nutritional support

Answer 84

ANS: A The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures, such as treatment with corticosteroids or immune globulin and nutritional support, to prevent or treat cirrhosis.

Question 85

What is the earliest clinical manifestation of biliary atresia? a. Jaundice b. Vomiting c. Hepatomegaly d. Absence of stooling

Answer 85

ANS: A Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera and may be present at birth, but is usually not apparent until ages 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile.

Question 86

The nurse, caring for a neonate with a suspected tracheoesophageal fistula, should include what intervention into the plan of care? a. Elevating the head to facilitate secrete drainage. b. Elevating the head for feedings only. c. Feeding glucose water only. d. Avoiding suctioning unless the infant is cyanotic.

Answer 86

ANS: A When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees to maintain an airway and facilitate drainage of secretions. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feeding of fluids should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

Question 87

Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Incarcerated hernia c. Omphalocele d. Strangulated hernia

Answer 87

ANS: D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. An incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intraabdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum and not skin

Question 88

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation

Answer 88

ANS: C Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds, are usually not present. The upper abdomen is distended, not the lower abdomen.

Question 89

What is the most appropriate nursing action when a child with a probable intussusception has a normal, brown stool? a. Notify the practitioner b. Measure abdominal girth c. Auscultate for bowel sounds d. Take vital signs, including blood pressure

Answer 89

ANS: A Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic/therapeutic plan of care.

Question 90

An important nursing consideration in the care of a child with celiac disease is to facilitate which intervention? NURSINGTB.COM a. Refer to a nutritionist for detailed dietary instructions and education. b. Help the child and family understand that diet restrictions are usually only temporary. c. Teach proper hand washing and Standard Precautions to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms.

Answer 90

ANS: A The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.

Question 91

What is the major focus of the therapeutic management for a child with lactose intolerance? a. Compliance with the medication regimen b. Providing emotional support to family members c. Teaching dietary modifications d. Administration of daily normal saline enemas

Answer 91

ANS: C Simple dietary modifications are effective in the management of lactose intolerance. Symptoms of lactose intolerance are usually relieved after instituting a lactose-free diet. Medications are not typically ordered in the management of lactose intolerance. Providing emotional support to family members is not specific to this medical condition. Diarrhea is a manifestation of lactose intolerance. Enemas are contraindicated for this alteration in bowel elimination.

Question 92

What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal b. Rice cake c. Corn muffin d. Meat patty

Answer 92

ANS: A The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. Rice is an appropriate choice because it does not contain gluten. Corn is digestible because it does not contain gluten. Meats do not contain gluten and can be included in the diet of a child with celiac disease.

Question 93

Which description of a stool is characteristic of intussusception? a. Ribbon-like stools b. Hard stools positive for guaiac c. “Currant jelly” stools d. Loose, foul-smelling stools

Answer 93

ANS: C With intussusception, passage of bloody mucus-coated stools occurs. Pressure on the bowel from obstruction leads to passage of “currant jelly” stools. Ribbon-like stools are characteristic of Hirschsprung’s disease. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

Question 94

What should the nurse stress in a teaching plan for the mother of an 11-year-old diagnosed with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers

Answer 94

ANS:D Coping with the stress of chronic illness and the clinical manifestations associated with ulcerative colitis (diarrhea, pain) are important teaching foci. Avoidance of triggers can help minimize the impact of the disease and its effect on the child. Ulcerative colitis is not infectious. Although nutritional guidance is a priority teaching focus, diarrhea is a problem with ulcerative colitis, not constipation. Daily enemas are not part of the therapeutic plan of care.

Question 95

Careful hand washing before and after contact can prevent the spread of which condition in day care and school settings? a. Irritable bowel syndrome b. Ulcerative colitis c. Hepatic cirrhosis d. Hepatitis A

Answer 95

ANS: D Hepatitis A is spread person to person, by the fecal-oral route, and through contaminated food or water. Good hand washing is critical in preventing its spread. The virus can survive on contaminated objects for weeks. Irritable bowel syndrome is the result of increased intestinal motility and is not contagious. Ulcerative colitis and cirrhosis are not infectious.

Question 96

Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines

Answer 96

ANS:B Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.

Question 97

An infant diagnosed with pyloric stenosis experiences excessive vomiting that can result in which condition? a. Hyperchloremia b. Hypernatremia c. Metabolic acidosis d. Metabolic alkalosis

Answer 97

ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Chloride ions and sodium are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.

Question 98

The nurse, caring for an infant whose cleft lip was repaired, should include which interventions into the infant’s postoperative plan of care? (Select all that apply.) a. Postural drainage b. Petroleum jelly to the suture line c. Elbow restraints d. Supine and side-lying positions e. Mouth irrigations

Answer 98

ANS: B, C Apply petroleum jelly to the operative site for several days after surgery. Elbows are restrained to prevent the child from accessing the operative site for up to 7 to 10 days. The child should be positioned on back or side or in an infant seat. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. Mouth irrigations would not be indicated.

Question 99

Which statements regarding hepatitis B are correct? (Select all that apply.) a. Hepatitis B cannot exist in a carrier state. b. Hepatitis B can be prevented by hepatitis B virus vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. The onset of hepatitis B is insidious. e. Immunity to hepatitis B occurs after one attack.

Answer 99

ANS: B, C, D, E The vaccine elicits the formation of an antibody to the hepatitis B surface antigen, which is protective against hepatitis B. Hepatitis B can be transferred to an infant of a breastfeeding mother, especially if the mother’s nipples are cracked. The onset of hepatitis B is insidious. Immunity develops after one exposure to hepatitis B. Hepatitis B can exist in a carrier state.

Question 100

Which interventions should a nurse implement when caring for a child with hepatitis? (Select all that apply.) a. Provide a well-balanced, low-fat diet. b. Schedule playtime in the playroom with other children. c. Teach parents not to administer any over-the-counter medications. d. Arrange for home schooling because the child will not be able to return to school. e. Instruct parents on the importance of good hand washing

Answer 100

ANS: A, C, E The child with hepatitis should be placed on a well-balanced, low-fat diet. Parents should be taught to not give over-the-counter medications because of impaired liver function. Hand hygiene is the most important preventive measure for the spread of hepatitis. The child will be in contact isolation in the hospital, so playtime with other hospitalized children is not scheduled. The child will be on contact isolation for a minimum of 1 week after the onset of jaundice. After that period, the child will be allowed to return to school.

Question 101

A mother who intended to breastfeed has given birth to an infant with a cleft palate. Which nursing interventions should be included in the plan of care? (Select all that apply.) a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.

Answer 101

ANS: B, D The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infant’s oral cavity so that the tongue action facilitates milk expression. The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated.