Nokea
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: The correct answer is A: abdominal pain related to decreased peristalsis. Ulcerative colitis causes inflammation and ulcers in the colon, leading to abdominal pain due to decreased peristalsis. This impairs the movement of stool through the colon, resulting in pain.
Choice B is incorrect as diarrhea is a common symptom of ulcerative colitis, not hyperosmolar intestinal contents. Choice C is incorrect as ulcerative colitis often leads to diarrhea and not fluid volume excess. Choice D is incorrect as activity intolerance is not directly related to ulcerative colitis, whereas abdominal pain is a common symptom associated with the condition.
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Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
- A. A sudden raise in BP may occur during the first 1-3 hours after the initial dose
- B. A sudden drop in BP may occur during the first 1-3 hours after the initial dose
- C. A sudden drop in body temperature may occur during the first 1-3hours after the initial dose
- D. A sudden rise in pulse rate may occur during the first 1-3 hours after the initial dosage CARING WITH CLIENTS WITH CEREBROVASCULAR DISORDER
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications.
Incorrect choices:
A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors.
C: Angiotensin converting enzyme inhibitors do not affect body temperature.
D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate.
In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.
A nurse is gathering information about a patients habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?
- A. Carefully review lab results.
- B. Conduct the physical assessment.
- C. Perform a thorough nursing health history.
- D. Prolong the termination phase of the interview.
Correct Answer: C
Rationale: The correct answer is C: Perform a thorough nursing health history. This method is the best for gathering information about a patient's habits and lifestyle patterns because it involves asking specific questions related to the patient's daily routines, habits, and lifestyle choices. By obtaining a comprehensive health history, the nurse can gather valuable information about the patient's diet, exercise habits, sleep patterns, stress levels, substance use, and other lifestyle factors that may impact their health. Reviewing lab results (A) may provide some information but not specifically about habits and lifestyle. Conducting a physical assessment (B) focuses more on the patient's physical condition rather than lifestyle. Prolonging the termination phase of the interview (D) is not a method of data collection and does not focus on gathering information about habits and lifestyle patterns.
During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi’s sarcoma
Correct Answer: D
Rationale: The correct answer is D: Kaposi’s sarcoma. In AIDS patients, Kaposi’s sarcoma is a common cancer caused by human herpesvirus 8. It presents as purple or brown skin lesions. Squamous cell carcinoma (A), leukemia (B), and multiple myeloma (C) are not commonly associated with AIDS. Squamous cell carcinoma is linked to sun exposure, leukemia originates in the bone marrow, and multiple myeloma is a cancer of plasma cells. Therefore, the correct answer is D due to its strong association with AIDS.
The nurse knows that a client understands a low residue diet when he selects which of the following from the menu?
- A. Rice and lean chicken
- B. Pasta with vegetables
- C. Strawberry pie
- D. Tuna casserole
Correct Answer: A
Rationale: The correct answer is A: Rice and lean chicken. A low residue diet aims to reduce fiber intake to ease digestion. Rice and lean chicken are low in fiber and easy to digest. Pasta with vegetables (B) contains high-fiber vegetables. Strawberry pie (C) is high in fiber due to fruit and crust. Tuna casserole (D) may contain high-fiber ingredients like noodles and vegetables. Therefore, A is the best choice for a low residue diet.
What should be included in the teaching plan to young adults about the spread of AIDS?
- A. Heterosexual transmission of HIV is on the rise
- B. The increase of HIV in children is primarily attributed to the rise in sexual abuse
- C. Herpes zoster is a form of the HIV virus
- D. Transmission of HIV by IV drug users is prominent even when sterile equipment is used
Correct Answer: A
Rationale: The correct answer is A because educating young adults about the rise in heterosexual transmission of HIV is crucial to prevent the spread of AIDS. This information helps them understand the importance of safe sex practices and awareness of risks. Choice B is incorrect as HIV transmission in children is not primarily due to sexual abuse. Choice C is also incorrect as herpes zoster is not a form of the HIV virus. Choice D is incorrect as transmission by IV drug users is not prominent with sterile equipment use. Focusing on the rise in heterosexual transmission is key in teaching young adults about AIDS prevention.