Nokea
A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Distended abdomen
- B. Temperature of 100.0°F (37.8°C)
- C. Loose and bloody stool
- D. Abdominal cramps
Correct Answer: A
Rationale: Colonic strictures predispose the client to intestinal obstruction. A distended abdomen may indicate an obstruction, requiring urgent notification of the provider. Low-grade fever, loose and bloody stools, and abdominal cramps are common symptoms of Crohn's disease and do not require immediate intervention.
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After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?
- A. I must clean my rectal area with warm water after each stool and apply zinc oxide ointment.
- B. I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel.
- C. I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry.
- D. I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.
Correct Answer: B
Rationale: Toilet paper can irritate sensitive perineal skin, so warm water rinses or a soft cotton washcloth should be used instead. Aloe vera is not effective for protecting skin from the excoriating effects of liquid stools. The other options describe appropriate care to prevent further irritation.
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 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.
A nurse cares for an older adult client who has Salmonella food poisoning. The clients vital signs are heart rate: 102 beats/min, blood pressure: 98/56 mm Hg. Which statement by the client indicates a need for additional teaching?
- A. I should not prepare food for others while I am sick.
- B. I will take the ciprofloxacin until the diarrhea has resolved.
- C. I should wash my hands with antibacterial soap before each meal.
- D. I must place my dishes into the dishwasher after each meal.
Correct Answer: B
Rationale: Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection and should not be stopped once diarrhea resolves. Clients must complete the full course of antibiotics to prevent recurrence and resistance. Not preparing food for others, washing hands with antibacterial soap, and cleaning dishes thoroughly are correct practices to prevent the spread of infection.
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.