Nokea
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?
- A. An intestinal obstruction has developed.
- B. Additional ulcers have developed.
- C. The esophagus has become inflamed.
- D. The ulcer has perforated.
Correct Answer: D
Rationale: Sudden, sharp midepigastric pain with a rigid, boardlike abdomen strongly suggests ulcer perforation, a life-threatening complication requiring urgent intervention. The other options do not align with these clinical manifestations.
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Which of the following has been identified as a potential risk factor for the development of colon cancer?
- A. Chronic constipation.
- B. Long-term use of laxatives.
- C. History of smoking.
- D. History of inflammatory bowel disease.
Correct Answer: D
Rationale: A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet. CN: Reduction of risk potential; CL: Analyze
Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?
- A. Encourage the client to breathe shallowly.
- B. Have the client practice abdominal breathing.
- C. Offer the client inceptive spirit.
- D. Teach the client to splint the rib cage when coughing.
Correct Answer: D
Rationale: Splinting the rib cage during coughing stabilizes the chest, reducing pleuritic pain. Shallow breathing may worsen atelectasis. Abdominal breathing aids ventilation but not pain. 'Inceptive spirit' is likely a typo for incentive spirometry, which promotes lung expansion but not direct pain relief.
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
- A. Double vision.
- B. Sudden bursts of energy.
- C. Weakness in the extremities.
- D. Muscle tremors.
Correct Answer: B
Rationale: Sudden bursts of energy are not typical in MS, which often causes fatigue. Double vision, weakness, and tremors are common due to demyelination affecting vision, motor, and coordination.
The nurse is performing discharge education to an older adult diagnosed with cataracts. Which of the following statements indicates effective understanding?
- A. I may have to quit driving until I get the cataracts treated.'
- B. I should spend less time outdoors in the sun and plan more activities at night.'
- C. I will need to avoid activities that raise my intraocular pressure, such as bending at the waist.'
- D. I will have to be careful since my eyes won't move together.'
Correct Answer: A
Rationale: Cataracts can impair vision, making driving unsafe until treated. Sun exposure does not directly affect cataracts, intraocular pressure is not a primary concern, and eye movement misalignment is not typical.
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
- A. Assume decision making for the client.
- B. Encourage the client's compliance with all treatment regimens.
- C. Inform the client of all possible adverse treatment effects.
- D. Identify available resources.
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.