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A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the patients most recent laboratory tests, the nurse should prioritize which of the following?
- A. White blood cell level
- B. Creatinine level
- C. Hemoglobin level
- D. Potassium level
Correct Answer: D
Rationale: In elderly patients, it is important to monitor the patients serum electrolyte levels closely. Diarrhea is less likely to cause an alteration in white blood cell, creatinine, and hemoglobin levels.
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A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale?
- A. To treat any undiagnosed infections
- B. To reduce intestinal bacteria levels
- C. To reduce bowel motility
- D. To reduce abdominal distention postoperatively
Correct Answer: B
Rationale: Antibiotics such as kanamycin (Kantrex), neomycin (Mycifradin), and cephalexin (Keflex) are administered orally the day before surgery to reduce intestinal bacteria. Preoperative antibiotics are not given to treat undiagnosed infections, reduce motility, or prevent abdominal distention.
A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis?
- A. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake
- B. Risk for Infection Related to Possible Rupture of Appendix
- C. Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake
- D. Chronic Pain Related to Appendicitis
Correct Answer: B
Rationale: The patient with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.
A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
- A. Development of new hemorrhoids
- B. Abdominal bloating and flank pain
- C. Unexplained weight gain
- D. Change in bowel habits
Correct Answer: D
Rationale: The most common presenting symptom associated with colorectal cancer is a change in bowel habits. The passage of blood is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. Hemorrhoids and bloating are atypical.
An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate?
- A. Anticholinergic medications
- B. Increased fiber intake
- C. Enemas on alternating days
- D. Reduced fat intake
- E. Fluid reduction
Correct Answer: B,D
Rationale: Patients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.
A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids?
- A. A 45-year-old teacher who stands for 6 hours per day
- B. A pregnant woman at 28 weeks gestation
- C. A 37-year-old construction worker who does heavy lifting
- D. A 60-year-old professional who is under stress
Correct Answer: B
Rationale: Hemorrhoids commonly affect 50% of patients after the age of 50. Pregnancy may initiate hemorrhoids or aggravate existing ones. This is due to increased constipation during pregnancy. The significance of pregnancy is greater than that of standing, lifting, or stress in the development of hemorrhoids.