Nokea
While performing a home visit, the nurse observes that the client’s head of the bed is raised on 6-in. blocks. The nurse should question the client for a history of which conditions?
- A. Hiatal hernia
- B. Dumping syndrome
- C. Crohn’s disease
- D. Gastroesophageal reflux disease
- E. Gastritis
Correct Answer: A, D
Rationale: Clients with a hiatal hernia are encouraged to sleep with the HOB elevated on 4- to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. B. Dumping syndrome occurs after surgery when the stomach no longer has control over the amount of chime that enters the small intestine. Clients are encouraged to lie flat after a meal. C. Crohn’s disease is an inflammatory disease of the bowel. Positioning interventions do not decrease symptoms. D. Clients with GERD are encouraged to sleep with the HOB elevated on 4— to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. E. Gastritis is inflammation of the gastric mucosa. Positioning interventions do not decrease symptoms.
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The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?
- A. My stoma should be pink and moist.
- B. I will irrigate my ileostomy every morning.
- C. If I get a red, bumpy, itchy rash I will call my HCP.
- D. I will change my pouch if it starts leaking.
Correct Answer: B
Rationale: Ileostomies typically do not require routine irrigation, as the output is liquid and continuous, unlike colostomies. The other statements reflect correct understanding of stoma care and management.
The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching?
- A. If diarrhea persists for more than 96 hours, contact the health-care provider.
- B. Instruct the client to wash hands thoroughly before handling any type of food.
- C. Explain the importance of decreasing steroids gradually as instructed.
- D. Discuss how to collect all stool samples for the next 24 hours.
Correct Answer: B
Rationale: Handwashing prevents the spread of gastroenteritis, a key discharge teaching point. Persistent diarrhea is concerning but less specific, steroids are irrelevant, and stool collection is not routine.
The 40-year-old client is recovering from an exacerbation of chronic pancreatitis. As the client prepares for discharge, the client makes several statements to the nurse. Which statement should be concerning because it could inhibit the client’s ability to accomplish the developmental tasks of middle adulthood?
- A. “I’m planning on continuing to be active in the local town service club.”
- B. “I enjoy my job; I should be able to return to work in about 3 to 4 weeks.”
- C. “I’ve missed friends and look forward to having a glass of wine with them.”
- D. “My spouse has been very supportive during my lengthy hospitalization.”
Correct Answer: C
Rationale: A. Volunteer activities meet the developmental task of middle adulthood of generativity. B. Planning to return to work meets the developmental task of middle adulthood of generativity. C. Consuming alcohol will cause continued progression of the pancreatic disease and could eventually result in the inability to work or to participate in community service. This statement should be concerning to the nurse. D. This statement indicates that the client has the support of another.
The RN overhears the LPN talking with the client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. Which statement made by the LPN should the RN clarify to decrease the client’s anxiety?
- A. “This surgery will prevent you from developing colon cancer.”
- B. “After this surgery you will no longer have ulcerative colitis.”
- C. “After surgery you may not have solid food for several days.”
- D. “You’ll have a permanent ileostomy after having this surgery.”
Correct Answer: D
Rationale: A. The client will not be at risk for colon cancer because with a total colectomy the entire colon is removed. B. Since this surgery removes the total colon, the ulcerative colitis will be cured. C. The client will be unable to eat until peristalsis returns, and then it may take several days before solid foods are tolerated. D. The client will initially have an ileostomy; after the reservoir has healed, the ileostomy will be closed. Knowing that the ileostomy will be temporary is important information for the client to decrease anxiety.
The nurse has been assigned to care for four clients. Which client should the nurse plan to assess first?
- A. The 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numerical scale
- B. The 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes
- C. The 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night
- D. The 54-year-old client with cirrhosis and jaundice who is reporting having itching all over the body
Correct Answer: B
Rationale: A. The client with a pain rating of 6 out of 10 on a numerical scale needs attention, but the pain is not a life-threatening concern. B. Bleeding esophageal varices are the most life-threatening complication of cirrhosis. Coughing can precipitate a bleeding episode. The nurse should assess this client first. C. The client who is postcholecystectomy is reported as being stable and could be assessed last. D. The client reporting itching needs attention, but the itching is not a life-threatening concern.