Nokea
A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
- A. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
- B. It is critical to report promptly to your health care provider any findings of peptic ulcers
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
- D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
Correct Answer: B
Rationale: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite.
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The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
- A. We will call the health care provider if the child develops acne.'
- B. Our child should brush and floss carefully after every meal.'
- C. We will skip the next dose if vomiting or fever occur.'
- D. When our child is seizure-free for 6 months, we can stop the medication.'
Correct Answer: B
Rationale: Our child should brush and floss carefully after every meal.' Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.
The nurse is preparing to change the soiled bed linens of the client with acute diarrhea of unknown origin. Which interventions should the nurse implement? Select all that apply.
- A. Wear a mask while changing the soiled linens
- B. Wear gown and gloves while in the room
- C. Use alcohol-based hand wash before and after care
- D. Request that the HCP prescribe a stool culture
- E. Post an enteric precaution sign outside the room
Correct Answer: B,D,E
Rationale: B: Gown and gloves protect against potential infectious stool. D: A stool culture identifies the cause. E: Enteric precautions prevent transmission. A: Masks are unnecessary for non-airborne pathogens. C: Soap and water are needed for possible C. difficile.
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct Answer: C
Rationale: accept the client's report of pain. Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain -- 'the client's report.'
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
The nurse is completing a variance report after finding a plastic bag at the nurse's station with contents and the sticker illustrated. The nurse should document finding a plastic bag with a symbol indicating that the contents of the bag include which type of item?
- A. Potentially infectious specimen
- B. Radioactive medication
- C. Flammable substance
- D. Poisonous substance
Correct Answer: A
Rationale: A: The biohazard symbol indicates potentially infectious material. B, C, D: Other symbols (trefoil, NFPA diamond) denote radiation, flammability, or toxicity.