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A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
- A. abdominal pain related to decreased peristalsis
- B. diarrhea related to hyperosmolar intestinal contents
- C. fluid volume excess related to increase water absorption by intestinal mucosa
- D. activity intolerance related to fatigue
Correct Answer: A
Rationale: Among the given choices, the nursing diagnosis appropriate for a client with ulcerative colitis is "abdominal pain related to decreased peristalsis." Ulcerative colitis is a chronic inflammatory bowel disease that directly affects the lining of the colon and rectum, leading to symptoms such as abdominal pain, diarrhea, and bloody stool. Decreased peristalsis occurs in patients with ulcerative colitis, resulting in abdominal pain due to inflammation and irritation of the intestines. This pain is a common symptom experienced by individuals with ulcerative colitis and can significantly impact their quality of life. Therefore, addressing the client's abdominal pain is crucial in providing effective nursing care for someone diagnosed with ulcerative colitis.
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Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
- A. Loosening constrictive clothing
- B. Opening the patient's jaw and inserting a mouth gag
- C. Positioning the patient on his or her side with head flexed forward
- D. Providing for privacy
Correct Answer: B
Rationale: Opening the patient's jaw and inserting a mouth gag is not part of the appropriate nursing care for a patient experiencing a convulsive seizure. Doing so can potentially harm the patient by causing injury to the teeth, jaw, or airway. It is important to protect the patient's airway during a seizure, but this can be done by positioning the patient on their side with the head flexed forward, ensuring a clear airway without the need for a mouth gag.
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
- A. Radiation therapy
- B. Chemotherapy
- C. Major surgery
- D. None
Correct Answer: C
Rationale: In the case of stage IV ovarian cancer, initial treatment typically involves major surgery, known as cytoreductive surgery or debulking surgery. The goal of this surgery is to remove as much of the tumor burden as possible from the abdomen and pelvis. By reducing the size of the tumor, the effectiveness of subsequent treatments such as chemotherapy can be enhanced. Surgery may also involve the removal of the uterus, ovaries, fallopian tubes, and surrounding tissue. Radiation therapy or chemotherapy may be used after surgery to further target any remaining cancer cells. However, major surgery is often the first step in the management of advanced ovarian cancer.
Which of the following blood types would the nurse identify as the rarest?
- A. A
- B. AB
- C. B
- D. O
Correct Answer: B
Rationale: Blood type AB is the rarest of all the blood types. This is because individuals with AB blood type have both A and B antigens on their red blood cells, making it less common than other blood types. In the ABO blood group system, the distribution of blood types in the general population is approximately 45% type O, 40% type A, 11% type B, and only about 4% type AB. Therefore, blood type AB would be identified as the rarest in the given options.
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
- A. Protein
- B. Vitamin A
- C. Fat
- D. Zinc
Correct Answer: C
Rationale: Excessive ingestion of fat has been linked to autoimmunity. A diet high in saturated and trans fats can lead to chronic inflammation and disrupt the balance of immune cells, potentially triggering autoimmune responses in the body. Conversely, a nutritionally balanced diet that includes healthy fats like omega-3 fatty acids from sources such as fish, nuts, and seeds can help support optimal immunologic function and reduce the risk of autoimmune disorders.
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
- A. Placement of IV and central venous pressure lines
- B. Administrating cleansing enemas
- C. Observing for leakage of urine or stool from the anastomosis
- D. Assessing the clients ability to manage self catheterization
Correct Answer: C
Rationale: When a client undergoes treatment for a malignant tumor requiring a urinary diversion procedure, such as a urostomy, it is crucial for nurses to closely monitor for any signs of leakage of urine or stool from the anastomosis site. This is important because it can indicate complications such as infection, poor wound healing, or a breakdown in the surgical site. Detecting and addressing leakage promptly can help prevent further complications and ensure the client's recovery progresses smoothly. While the other options may be important aspects of nursing care, observing for leakage of urine or stool from the anastomosis is the most critical factor in managing clients undergoing treatment for a malignant tumor affecting the urinary system.