Nokea
Results of a patient's preliminary assessment prompted an examination of the patient's carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurse's most appropriate response to this finding?
- A. Perform a focused abdominal assessment.
- B. Prepare to meet the patient's psychosocial needs.
- C. Liaise with the nurse practitioner to perform an anorectal examination.
- D. Encourage the patient to adhere to recommended screening protocols.
Correct Answer: B
Rationale: CEA is a protein that is normally not detected in the blood of a healthy person; therefore, when detected it indicates that cancer is present, but not what type of cancer is present. The patient would likely be learning that he or she has cancer, so the nurse must prioritize the patient's immediate psychosocial needs, not abdominal assessment. Future screening is not a high priority in the short term.
You may also like to solve these questions
A nurse is providing preprocedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation?
- A. You'll need to fast for at least 18 hours prior to your test.
- B. Starting today, take over-the-counter stool softeners twice daily.
- C. You'll need to have enemas the day before the test.
- D. For 24 hours before the test, insert a glycerin suppository every 4 hours.
Correct Answer: C
Rationale: Preparation of the patient includes emptying and cleansing the lower bowel. This often necessitates a low-residue diet 1 to 2 days before the test; a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear the following morning.
A patient has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test?
- A. Impaired Dentition Related to Gingivitis
- B. Risk For Impaired Skin Integrity Related to Peptic Ulcers
- C. Imbalanced Nutrition: Less Than Body Requirements Related to Enzyme Deficiency
- D. Diarrhea Related to Clostridium Difficile Infection
Correct Answer: B
Rationale: Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. This test does not address fluid volume, nutritional status, or dentition.
A patient has come to the clinic complaining of blood in his stool. A FOBT test is performed but is negative. Based on the patient's history, the physician suggests a colonoscopy, but the patient refuses, citing a strong aversion to the invasive nature of the test. What other test might the physician order to check for blood in the stool?
- A. A laparoscopic intestinal mucosa biopsy
- B. A quantitative fecal immunochemical test
- C. Computed tomography (CT)
- D. Magnetic resonance imagery (MRI)
Correct Answer: B
Rationale: Quantitative fecal immunochemical tests may be more accurate than guaiac testing and useful for patients who refuse invasive testing. CT or MRI cannot detect blood in stool. Laparoscopic intestinal mucosa biopsy is not performed.
An inpatient has returned to the medical unit after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding should the nurse report to the physician?
- A. Large, wide stools
- B. Milky white stools
- C. Three stools during an 8-hour period of time
- D. Streaks of blood present in the stool
Correct Answer: D
Rationale: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.
A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of?
- A. Diet high in red meat
- B. Upper GI bleed
- C. Hemorrhoids
- D. Use of iron supplements
Correct Answer: C
Rationale: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.