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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 recovering from acute pancreatitis who has been NPO asks the nurse, “When can I start eating again?” Which response by the nurse is most accurate?
- A. “As soon as you start to feel hungry you can begin eating.”
- B. “When I hear that your bowel sounds are active and you are passing flatus.”
- C. “When your pain is controlled and your serum lipase level has decreased.”
- D. “You will be NPO for at least more 2 weeks; oral intake stimulates the pancreas.”
Correct Answer: C
Rationale: A. Regaining appetite is a positive sign, but it must be accompanied by a decrease in pain before the client is allowed to take food orally. B. Intestinal peristalsis may be slowed due to inflammation associated with acute pancreatitis, but the return of bowel sounds and flatus is not used to determine when to begin oral intake. C. This response is correct. Once pain is controlled and the serum enzyme levels begin to decrease, the client can begin oral intake. These are signs that the pancreas is healing. D. There is no specific time limit for being NPO.
The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney's point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response?
- A. The next time the doctor comes in, we should ask him what he meant by that.'
- B. I've felt that I don't understand the doctor at times either.'
- C. That is the term used to indicate that the pain has traveled to the right lower side.'
- D. McBurney's point refers to severe pain for which surgery is the only treatment.'
Correct Answer: C
Rationale: McBurney's point is the area in the right lower quadrant where appendicitis pain localizes, indicating inflammation of the appendix.
The nurse is caring for the client diagnosed with hepatic encephalopathy. Which sign and symptom indicate the disease is progressing?
- A. The client has a decrease in serum ammonia level.
- B. The client is not able to circle choices on the menu.
- C. The client is able to take deep breaths as directed.
- D. The client is able to eat previously restricted food items.
Correct Answer: B
Rationale: Inability to circle menu choices indicates worsening cognitive function, a sign of progressing hepatic encephalopathy. Decreased ammonia, following directions, and eating are positive or unrelated.
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 preparing to hang a new bag of total parenteral nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?
Correct Answer: 83 mL/hr
Rationale: Total volume = 1,500 + 10 + 20 + 20 + 500 = 2,050 mL. Infusion over 24 hours: 2,050 ÷ 24 = 85.42 mL/hr, rounded to 83 mL/hr for pump settings.