Nokea
The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation?
- A. An elevated white blood cell (WBC) count.
- B. A decreased lactate dehydrogenase (LDH).
- C. An elevated alkaline phosphatase.
- D. A decreased direct bilirubin level.
Correct Answer: C
Rationale: Chronic cholecystitis often causes elevated alkaline phosphatase due to bile duct irritation or obstruction. WBC elevation is more acute, and bilirubin or LDH changes are less specific.
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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.
The nurse is assessing a client complaining of abdominal pain. Which data support the diagnosis of a bowel obstruction?
- A. Steady, aching pain in one specific area.
- B. Sharp back pain radiating to the flank.
- C. Sharp pain increases with deep breaths.
- D. Intermittent colicky pain near the umbilicus.
Correct Answer: D
Rationale: Intermittent colicky pain near the umbilicus is characteristic of bowel obstruction due to peristalsis against the blockage. Steady pain, back pain, and pain with breathing suggest other conditions.
The client is diagnosed with ulcerative colitis. Which sign/symptom warrants immediate intervention by the nurse?
- A. The client has 20 bloody stools a day.
- B. The client's oral temperature is 99.8°F.
- C. The client's abdomen is hard and rigid.
- D. The client complains of urinating when coughing.
Correct Answer: C
Rationale: A hard, rigid abdomen suggests peritonitis or perforation, a life-threatening complication of ulcerative colitis requiring immediate intervention. Frequent bloody stools are expected, low-grade fever is less urgent, and urinary incontinence is unrelated.
The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session?
- A. Discuss the importance of drinking 1,000 mL of water daily.
- B. Instruct the client to exercise at least three (3) times a week.
- C. Teach the client about eating a low-residue diet.
- D. Explain the need to have daily bowel movements.
Correct Answer: B
Rationale: Regular exercise promotes bowel motility, reducing the risk of diverticulitis in diverticulosis. A high-fiber diet (not low-residue) is recommended, 1,000 mL of water is insufficient, and daily bowel movements are not mandatory.
The female client diagnosed with anorexia nervosa is admitted to the hospital. The client is 67 inches tall and weighs 40 kg. Which client problem has the highest priority?
- A. Altered nutrition.
- B. Low self-esteem.
- C. Disturbed body image.
- D. Altered sexuality.
Correct Answer: A
Rationale: Altered nutrition is the priority due to severe underweight (BMI ~13.2), risking organ failure and death. Self-esteem, body image, and sexuality are psychosocial and secondary.