Nokea
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?
- A. A severe steady right lower quadrant pain.
- B. Abdominal pain associated with nausea and vomiting
- C. Marked peristalsis and hyperactive bowel sounds.
- D. Abdominal pain that increases with knee flexion
Correct Answer: A
Rationale: Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Nausea and vomiting typically indicate gastroenteritis if they occur first. Marked peristalsis and hyperactive bowel sounds are not typical of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.
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After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback?
- A. I realize that you had a tough time today, but it will get easier with practice.
- B. You cleared the stoma well. Now you need to practice putting on the appliance.
- C. You seem to understand what I taught you today. What else can I help you with?
- D. You seem to understand. Do you want your daughter to care for your ostomy?
Correct Answer: B
Rationale: Feedback should be objective and constructive, acknowledging what was done well (clearing the stoma) and identifying areas for improvement (applying the appliance). General reassurance, vague inquiries, or suggesting someone else manage the ostomy are not constructive.
A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?
- A. Low-fiber diet
- B. Skin protection
- C. Antibiotic administration
- D. Blood glucose monitoring
Correct Answer: B
Rationale: A heavily draining fistula releases caustic intestinal fluids that can cause skin breakdown or infections. Skin protection is the priority to prevent complications. Nutrition, antibiotics, and glucose monitoring are important but secondary.
A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, 'I am having trouble swallowing this pill.' Which action should the nurse take?
- A. Contact the clinical pharmacist and request the medication in suspension form.
- B. Empty the contents of the medication into suspension or pudding for administration.
- C. Ask the health care provider to prescribe the medication as an enema instead.
- D. Crush the pill carefully and administer it in applesauce or pudding.
Correct Answer: C
Rationale: Asacol is an enteric-coated pill that should not be crushed, chewed, or broken, as this would disrupt its delayed-release mechanism. It is not available as a suspension or elixir. A mesalamine enema (Rowasa) is an alternative formulation that can be prescribed if the client cannot swallow the oral form.
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?
- A. Inspection of oral mucosa
- B. Review of recent dietary intake
- C. Heart rate and rhythm
- D. Percussion of abdomen
Correct Answer: C
Rationale: Severe diarrhea can lead to hypovolemia and electrolyte imbalances, such as low potassium or magnesium, which may cause dysrhythmias. Assessing heart rate and rhythm is the priority to detect potential cardiac complications. Oral mucosa inspection, dietary intake review, and abdominal percussion are important but lower priority.
A nurse cares for a client with ulcerative colitis. The client states, 'I feel like I am tied to the toilet. This disease is controlling my life.' How should the nurse respond?
- A. Let's identify stress factors that worsen your symptoms to help you gain more control.
- B. If you take the prescribed medications, you will no longer have diarrhea.
- C. To decrease distress, do not eat anything before you go out.
- D. You must take control of your life. I will consult a therapist to help.
Correct Answer: A
Rationale: Identifying stress factors that exacerbate ulcerative colitis symptoms empowers the client to manage their condition. Medications reduce but do not eliminate diarrhea, fasting is not practical, and suggesting a therapist without discussion dismisses the client's concerns.