Nokea
The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client?
- A. When was your last bowel movement?
- B. Did you have a high-fat meal last night?
- C. Can you describe the type of pain?
- D. Have you been experiencing any gas?
Correct Answer: C
Rationale: Describing the type of pain (e.g., sharp, dull, colicky) helps differentiate causes like appendicitis, diverticulitis, or obstruction, guiding diagnosis. Bowel movements, diet, and gas are secondary.
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A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
- A. Give him an enema one hour before the examination.
- B. Keep him NPO for eight hours before the examination.
- C. Order a low-fat, low-residue diet for breakfast.
- D. Administer enemas until the returns are clear this evening.
Correct Answer: A
Rationale: An enema one hour before sigmoidoscopy clears the sigmoid colon for better visualization.
Which assessment data indicate to the nurse the client's gastric ulcer has perforated?
- A. Complaints of sudden, sharp, substernal pain.
- B. Rigid, boardlike abdomen with rebound tenderness.
- C. Frequent, clay-colored, liquid stool.
- D. Complaints of vague abdominal pain in the right upper quadrant.
Correct Answer: B
Rationale: A rigid, boardlike abdomen with rebound tenderness indicates peritonitis, a common complication of ulcer perforation due to leakage of gastric contents into the peritoneal cavity. Substernal pain, clay-colored stools, and vague pain are less specific.
The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.
The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement?
- A. Perform a complete pain assessment.
- B. Assess the client's vital signs frequently.
- C. Administer a proton pump inhibitor intravenously.
- D. Obtain permission and administer blood products.
- E. Monitor the intake of a soft, bland diet.
Correct Answer: B,C,D
Rationale: Frequent vital sign assessment monitors for hypovolemia, IV proton pump inhibitors reduce acid and bleeding, and blood products treat anemia from hemorrhage. Pain assessment is important but less urgent, and a bland diet is inappropriate during active bleeding.
The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care?
- A. Allow any of the client's favorite foods as long as the amount is limited.
- B. Have the client perform eructation exercises several times a day.
- C. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes.
- D. Encourage the client to consume a glass of red wine with one (1) meal a day.
Correct Answer: C
Rationale: Eating small, frequent meals reduces stomach distension, which can trigger reflux, and limiting fluids during meals prevents excessive gastric volume. Favorite foods may include triggers, eructation exercises are not standard, and alcohol like red wine can worsen GERD.