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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 nurse identifies the client problem 'alteration in gastrointestinal system' for the elderly client. Which statement reflects the most appropriate rationale for this problem?
- A. Elderly clients have the ability to chew food more thoroughly with dentures.
- B. Elderly clients have an increase in digestive enzymes, which helps with digestion.
- C. Elderly clients have an increased need for laxatives because of a decrease in bile.
- D. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.
Correct Answer: C
Rationale: Elderly clients often have reduced peristalsis and bile production, leading to constipation and increased laxative need, supporting the GI alteration problem. Dentures, enzyme increase, and bacterial overgrowth are less accurate.
The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group?
- A. Do not share needles or equipment.
- B. Use barrier protection during sex.
- C. Get the hepatitis B vaccine.
- D. Obtain immune globulin injections.
- E. Avoid any type of hepatotoxic medications.
Correct Answer: A,B,C
Rationale: Preventing hepatitis B involves avoiding needle sharing, using condoms, and getting vaccinated, as it is bloodborne and sexually transmitted. Immune globulin is post-exposure, and hepatotoxic drugs are less relevant.
The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN?
- A. Assist the UAP to learn to perform blood glucose checks.
- B. Monitor the potassium levels of a client with diarrhea.
- C. Administer a bulk laxative to a client diagnosed with constipation.
- D. Assess the abdomen of a client who has had complaints of pain.
Correct Answer: C
Rationale: Administering a laxative is within the LPN’s scope. Teaching UAPs, monitoring labs, and abdominal assessments require RN skills.
The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.
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.