Nokea
Bowel sound assessment on a patient with an early bowel obstruction who has distention, nausea, and visible peristaltic waves will demonstrate which type of bowel sound?
- A. loud and clearly audible.
- B. high pitched.
- C. hyperactive.
- D. absent.
Correct Answer: B
Rationale: Because there are visible peristaltic waves, there will be bowel sounds that will be faint and high pitched.
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Why are peptic ulcers a common problem of aging?
- A. Older adults develop esophageal diverticula
- B. Older adults have a higher incidence of hiatal hernia
- C. Older adults use nonsteroidal anti-inflammatory drugs to treat chronic joint conditions
- D. Older adults have decreased secretion of hydrochloric acid from the parietal cells of the stomach.
Correct Answer: C
Rationale: Medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) taken for arthritis or degenerative joint conditions may contribute to ulcer formation.
Which will be the most helpful nursing intervention to increase the comfort of a patient with appendicitis?
- A. Applying of ice bag
- B. Administration of small tap water enema
- C. Warm compress over entire abdomen
- D. Ambulate for short periods in the room
Correct Answer: A
Rationale: Applying of an ice bag will decrease the flow of blood to the area and impede the inflammatory process.
The home health nurse caring for a patient who has dysarthria related to radiation therapy for an oral cancer would recommend that the family provide which device?
- A. a tablet and pencil as a communication aid.
- B. a TV for diversion.
- C. a bell to summon help.
- D. a walkie-talkie.
Correct Answer: A
Rationale: The provision of an alternative method of communicating will lessen the frustration of the patient who has trouble speaking understandably. The call bell would be helpful also, but without a way to communicate, the bell is not as essential as a method of communication.
A male patient reports that he will never adjust to his colostomy. Which is the best action for the nurse in this situation?
- A. Encourage him to express his concern.
- B. Suggest that he discuss his concerns with his physician.
- C. Counsel him that everything will be all right.
- D. Assure him that his concerns will diminish when he is able to care for his colostomy.
Correct Answer: A
Rationale: When a colostomy is performed, the patient or significant other should be able to verbalize concerns about the ostomy to the nurse.
The nurse caring for a patient with Crohn disease will closely monitor the urinary output to ensure that the patient is excreting at least mL/day.
- A. 1500
Correct Answer: 1500
Rationale: The output of 1500 mL a day indicates good kidney perfusion. The disease allows such dramatic fluid loss that a constant watch on I&O is a major nursing intervention.