Nokea
A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?
- A. Ineffective coping related to fear of diagnosis of chronic illness
- B. Deficient knowledge related to unfamiliarity with significant signs and symptoms
- C. Constipation related to decreased gastric motility
- D. Imbalanced nutrition: Less than body requirements due to gastric bleeding
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of Acute Pain. The nurse would determine that the client has not met the expected outcomes if the client states
- A. That pain is relieved with histamine H2 receptor antagonists.
- B. That irritating foods have been eliminated from the diet.
- C. The client is being awakened at 2 AM with heartburn.
- D. The client has absence of pain before meals.
Correct Answer: C
Rationale: Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.
A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?
- A. Have the client drink 1000 mL of water.
- B. Ask the client about possible allergies to iodine or shellfish.
- C. Administer an intravenous contrast agent the evening before the test.
- D. Administer tap-water enemas until clear.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:
- A. Check that the hemostat is on the bedside
- B. Monitor IV fluids for the shift
- C. Regularly assess respiratory status
- D. Check that the balloon is deflated on a regular basis
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:
- A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion
- B. After insertion into the nostril, instruct the client to extend his neck
- C. Introduce the tube with the client's head tilted back, then instruct him to keep his head upright for final insertion
- D. Instruct the client to hold his chin down, then back for insertion of the tube
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Risk factors for the development of hiatal hernias are those that lead to increased abdominal pressure. Which of the following complications DOES NOT cause increased abdominal pressure?
- A. Obesity
- B. Volvulus
- C. Constipation
- D. Intestinal obstruction
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.