Nokea
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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After Billroth II surgery (gastrojejunostomy), the client experiences weakness, diaphoresis, anxiety, and palpitations 2 hours after a high-carbohydrate meal. The nurse should interpret that these symptoms indicate the development of which problem?
- A. Steatorrhea
- B. Duodenal reflux
- C. Hypervolemic fluid overload
- D. Postprandial hypoglycemia
Correct Answer: D
Rationale: A. Although steatorrhea may occur after gastric resection, the symptoms of steatorrhea include fatty stools with a foul odor, not these symptoms. B. The symptoms of duodenal reflux are abdominal pain and vomiting, not these symptoms. Duodenal reflux is not associated with food intake. C. Symptoms of fluid overload would include increased BP, edema, and weight gain, not these symptoms. D. When eating large amounts of carbohydrates at a meal, the rapid glucose absorption from the chime results in hyperglycemia. This elevated glucose stimulates insulin production, which then causes an abrupt lowering of the blood glucose level. Hypoglycemic symptoms of weakness, diaphoresis, anxiety, and palpitations occur.
The nurse is assigned to four clients who were diagnosed with gastric ulcers. Which client should be the nurse’s priority when monitoring for GI bleeding?
- A. The 40-year-old client who is positive for Helicobacter pylori (H. pylori)
- B. The 45-year-old client who drinks 4 ounces of alcohol a day
- C. The 70-year-old client who takes daily baby aspirin of 81 mg
- D. The 30-year-old pregnant client taking acetaminophen prn
Correct Answer: C
Rationale: A. The presence of H. pylori has not been proven to predispose to GI bleeding. B. Although alcohol is associated with gastric mucosal injury, its causative role in bleeding is unclear. C. It is most important for the nurse to monitor the 70-year-old client who is taking aspirin. The client has two risk factors for GI bleeding: age and taking aspirin. D. Pregnancy and acetaminophen usage do not predispose to GI bleeding.
The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement?
- A. Apply a heating pad to the abdomen for 15 to 20 minutes.
- B. Administer morphine sulfate intravenously after diluting with saline.
- C. Contact the surgeon for an order to x-ray the right shoulder.
- D. Apply a sling to the right arm, which was injured during surgery.
Correct Answer: B
Rationale: Right shoulder pain post-laparoscopic cholecystectomy is often referred pain from CO2 used in the procedure irritating the diaphragm. IV morphine relieves pain effectively. Heating pads, x-rays, or slings are inappropriate.
The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care?
- A. Instruct the client to cough forcefully.
- B. Encourage early ambulation.
- C. Assess for return of a gag reflex.
- D. Administer held medications.
Correct Answer: C
Rationale: ERCP involves throat anesthesia, so assessing the gag reflex ensures safe swallowing post-procedure. Coughing, ambulation, and medications are secondary.
The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement?
- A. Instruct the client to take a cathartic laxative daily.
- B. Encourage the client to drink lots of Gatorade.
- C. Discuss the need to increase protein in the diet.
- D. Explain the client should weigh herself daily.
Correct Answer: B
Rationale: Frequent diarrhea risks dehydration and electrolyte loss; Gatorade replaces fluids and electrolytes. Laxatives worsen diarrhea, protein is secondary, and daily weights are less urgent.