Nokea
A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find?
- A. Positive Murphy's sign with rebound tenderness to palpation
- B. Dull, hypoactive bowel sounds in the lower abdominal quadrant
- C. High-pitched, rushing bowel sounds in the right lower quadrant
- D. Reports of abdominal cramping that is worse at night
Correct Answer: C
Rationale: High-pitched, rushing bowel sounds are expected in Crohn's disease due to narrowing of the bowel lumen. Positive Murphy's sign indicates gallbladder disease, and rebound tenderness suggests peritonitis. Dull, hypoactive bowel sounds and nightly worsening of cramping are not typical of Crohn's disease.
You may also like to solve these questions
A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?
- A. Heart rate and rhythm
- B. Bowel sounds
- C. Urinary output
- D. Respiratory rate
Correct Answer: D
Rationale: Clostridium botulinum infection can cause respiratory failure due to neurotoxin effects. Assessing respiratory rate and oxygen saturation is the priority to detect early signs of respiratory compromise. Other assessments are important but secondary.
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.
A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?
- A. Metronidazole (Flagyl)
- B. Ciprofloxacin (Cipro)
- C. Sulfasalazine (Azulfidine)
- D. Ceftriaxone (Rocephin)
Correct Answer: A
Rationale: Metronidazole is the drug of choice for Giardia, a parasitic infection. Ciprofloxacin and ceftriaxone treat bacterial infections, and sulfasalazine is used for ulcerative colitis or Crohn's disease, not Giardia.
A nurse cares for a client with a new ileostomy. The client states, 'I don't think my friends will accept me with this ostomy.' How should the nurse respond?
- A. Your friends will be happy you are alive.
- B. Tell me more about your concerns.
- C. A therapist can help you resolve your concerns.
- D. With time you will accept your new body.
Correct Answer: B
Rationale: Encouraging the client to express concerns addresses social anxiety and apprehension common with a new ostomy. Minimizing concerns, suggesting a therapist without discussion, or assuming acceptance over time are not therapeutic responses.
A nurse assesses a client who is hospitalized for diverticulitis. The client's vital signs are temperature: 99.8°F (37.6°C), heart rate: 100 beats/min, respiratory rate: 18 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take first?
- A. Decrease stimulation and allow the client to rest.
- B. Stay with the client while another nurse calls the provider.
- C. Increase the client's intravenous fluid replacement rate.
- D. Check the client's blood glucose and administer orange juice.
Correct Answer: B
Rationale: The client's vital signs suggest possible hypovolemia or early sepsis due to diverticulitis (elevated heart rate, low blood pressure, and mild fever). Staying with the client and having another nurse contact the provider ensures rapid assessment and intervention. Rest, fluid rate increase, or glucose checks are not the priority without further assessment.