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A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis?
- A. I am a vegetarian.'
- B. My mother and grandmother have diabetes.'
- C. I take aspirin several times a day for tension headaches.'
- D. I take multivitamin and iron tablets every day.'
Correct Answer: C
Rationale: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Vegetarianism, family history of diabetes, and multivitamins with iron are not directly linked to duodenal ulcers.
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The nurse is facilitating a support group for clients diagnosed with Crohn's disease. Which information is most important for the nurse to discuss with the clients?
- A. Discuss coping skills to assist with adaptation to lifestyle modifications.
- B. Teach about drug administration, dosages, and scheduled times.
- C. Teach dietary changes necessary to control symptoms.
- D. Explain the care of the ileostomy and necessary equipment.
Correct Answer: A
Rationale: Coping skills help clients adapt to the chronic, unpredictable nature of Crohn’s disease, addressing psychosocial needs in a support group. Medications, diet, and ileostomy care are secondary.
The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD?
- A. Pyrosis, water brash, and flatulence.
- B. Weight loss, dysarthria, and diarrhea.
- C. Decreased abdominal fat, proteinuria, and constipation.
- D. Midepigastric pain, positive H. pylori test, and melena.
Correct Answer: A
Rationale: Pyrosis (heartburn), water brash (regurgitation of sour fluid), and flatulence are classic symptoms of GERD due to acid reflux and gas buildup. The other options include symptoms more associated with other conditions like peptic ulcer disease or systemic disorders.
The client has an eviscerated abdominal wound. Which intervention should the nurse implement?
- A. Apply sterile normal saline dressing.
- B. Use sterile gloves to replace protruding parts.
- C. Place the client in reverse Trendelenburg position.
- D. Administer intravenous antibiotic immediately (STAT).
Correct Answer: A
Rationale: Applying a sterile normal saline dressing keeps the eviscerated wound moist and protected until surgical repair. Replacing organs is contraindicated, reverse Trendelenburg is incorrect, and antibiotics are secondary.
The nurse is preparing to care for the client diagnosed with hepatitis A. Which interventions should the nurse plan to include?
- A. Teach the client to limit use of alcohol and drugs containing acetaminophen.
- B. Provide a high-protein, high-carbohydrate diet with three large meals per day.
- C. Wear gloves, mask, and gown when providing the client’s personal cares.
- D. Provide rest periods, alternating this with moderate activity during the day.
Correct Answer: D
Rationale: A. Clients with viral hepatitis should avoid all alcohol and all medications containing acetaminophen, not just limit their use. B. Clients should eat small, frequent meals with a high-carbohydrate, moderate-fat, and moderate-protein content. C. It is not necessary to wear a mask when caring for an individual with hepatitis A. A gown and gloves should be worn when in contact with blood and body fluids. D. Rest is an essential intervention to decrease the liver’s metabolic demands and increase its blood supply. Rest should be alternated with periods of activity to prevent complications and to restore health.
The clinic nurse is caring for a client who is 67 inches tall and weighs 100 kg. The client complains of occasional pyrosis, which resolves with standing or with taking antacids. Which treatment should the nurse expect the HCP to order?
- A. Place the client on a weight loss program.
- B. Instruct the client to eat three (3) balanced meals.
- C. Tell the client to take an antiemetic before each meal.
- D. Discuss the importance of decreasing alcohol intake.
Correct Answer: A
Rationale: Pyrosis (heartburn) in an overweight client (BMI ~33) suggests GERD, and weight loss reduces abdominal pressure and reflux. Balanced meals, antiemetics, and alcohol reduction are less primary.