Nokea
A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.
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The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective?
- A. I will have four (4) to five (5) small incisions.
- B. I will be in the hospital for at least one (1) week.
- C. I will not have any pain because this is laparoscopic surgery.
- D. I will be returning to work the day after my surgery.
Correct Answer: A
Rationale: Laparoscopic Nissen fundoplication involves 4–5 small incisions, indicating effective teaching. Hospital stays are shorter, pain is expected, and return to work takes longer.
Which assessment data indicate to the nurse the client's gastric ulcer has perforated?
- A. Complaints of sudden, sharp, substernal pain.
- B. Rigid, boardlike abdomen with rebound tenderness.
- C. Frequent, clay-colored, liquid stool.
- D. Complaints of vague abdominal pain in the right upper quadrant.
Correct Answer: B
Rationale: A rigid, boardlike abdomen with rebound tenderness indicates peritonitis, a common complication of ulcer perforation due to leakage of gastric contents into the peritoneal cavity. Substernal pain, clay-colored stools, and vague pain are less specific.
Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse?
- A. I will not drink any type of beer or mixed drink.
- B. I will get adequate rest so I don’t get exhausted.
- C. I had a big hearty breakfast this morning.
- D. I took some cough syrup for this nasty head cold.
Correct Answer: D
Rationale: Cough syrup may contain hepatotoxic ingredients (e.g., acetaminophen), posing a risk to a hepatitis patient’s liver, requiring immediate intervention. Other statements are appropriate or benign.
The nurse is caring for an elderly client diagnosed with acute gastritis. Which client problem is priority for this client?
- A. Fluid volume deficit.
- B. Altered nutrition: less than body requirements.
- C. Impaired tissue perfusion.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly clients with acute gastritis due to vomiting/diarrhea, risking dehydration. Nutrition, perfusion, and comfort are secondary.
The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent health-care associated infection (HAl) spread to other clients?
- A. Wash hands with Betadine for two (2) minutes after giving care.
- B. Wear nonsterile gloves when handling GI excretions.
- C. Clean the perianal area with soap and water after each stool.
- D. Flush the commode twice when disposing of stool.
Correct Answer: C
Rationale: Cleaning the perianal area with soap and water after each stool reduces the risk of Clostridium difficile spore transmission, which is critical for preventing healthcare-associated infections. Betadine is not standard, gloves are insufficient alone, and flushing twice is not evidence-based.