Nokea
A child with appendicitis is scheduled for surgery this evening. The nurse enters the room and sees the child's mother starting to place hot, wet washcloths on her daughter's abdomen so that 'she will feel better.' The nurse explains that this action is contraindicated because heat:
- A. can cause the appendix to rupture and cause peritonitis.
- B. can mask symptoms of acute appendicitis.
- C. will increase peristalsis throughout the abdomen.
- D. will arrest progression of the disease.
Correct Answer: A
Rationale: Heat can increase inflammation and blood flow, risking appendix rupture and peritonitis in appendicitis.
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The 25-year-old client, hospitalized with an exacerbation of distal ulcerative colitis, is prescribed mesalamine rectally via enema. The client states that an enema is disgusting and wants to know why the medication cannot be given orally. Which is the best response by the nurse?
- A. “It can be given orally; I’ll contact the doctor and see if the change can be made.”
- B. “Rectal administration delivers the mesalamine directly to the affected area.”
- C. “Oral administration is not possible for treating your ulcerative colitis exacerbation.”
- D. “It can be given orally; I’ll make the change, and we’ll tell the doctor in the morning.”
Correct Answer: B
Rationale: A. If the client still desires a change in medication route after the rationale for rectal administration is explained, the HCP should be consulted. B. This is the nurse’s best response because it explains the purpose for administration via enema. This route delivers mesalamine (Asacol) directly to the affected area, thus maximizing effectiveness and minimizing side effects. C. Oral administration is possible, but rectal administration is preferred in distal colitis. D. Nurses cannot order medications or change medication routes without specific approval by the HCP, who is licensed to prescribe medications.
The nurse is teaching the American Diabetes Association diet to a client diagnosed with diabetes mellitus type 2. Which should the nurse teach the client?
- A. Instruct the client to weigh all food before cooking it.
- B. Teach the client to eat only carbohydrates if the blood glucose is low.
- C. Demonstrate how to determine the amount of carbohydrates being eaten.
- D. Explain that proteins should be 75% of the recommended diet.
Correct Answer: C
Rationale: Determining carbohydrate amounts (e.g., carb counting) is key for glycemic control in type 2 diabetes per ADA guidelines. Weighing food, carb-only for hypoglycemia, and high protein are incorrect.
The client with liver problems asks the nurse, 'Why are my stools clay-colored?' On which scientific rationale should the nurse base the response?
- A. There is an increase in serum ammonia level.
- B. The liver is unable to excrete bilirubin.
- C. The liver is unable to metabolize fatty foods.
- D. A damaged liver cannot detoxify vitamins.
Correct Answer: B
Rationale: Clay-colored stools result from the liver’s inability to excrete bilirubin, which gives stool its brown color. Ammonia, fat metabolism, and vitamin detoxification are unrelated.
The 85-year-old male client diagnosed with cancer of the colon asks the nurse, 'Why did I get this cancer?' Which statement is the nurse's best response?
- A. Research shows a lack of fiber in the diet can cause colon cancer.
- B. It is not common to get colon cancer at your age; it is usually in young people.
- C. No one knows why anyone gets cancer, it just happens to certain people.
- D. Women usually get colon cancer more often than men but not always.
Correct Answer: A
Rationale: Low dietary fiber is a known risk factor for colon cancer, as it slows bowel transit and increases exposure to carcinogens. Colon cancer is common in older adults, not younger ones, and gender differences are minimal.
The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching?
- A. If I notice any skin breakdown, I will call the HCP.
- B. I should drink only liquids until the colostomy starts to work.
- C. I should not take a tub bath until the HCP okays it.
- D. I should not drive or lift more than five (5) pounds.
Correct Answer: B
Rationale: A liquid-only diet is unnecessary; a regular diet can be resumed as tolerated unless otherwise specified, as colostomies begin functioning soon after surgery. The other statements reflect correct colostomy care.