Nokea
The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply.
- A. Monitor diarrhea, charting amount, character, and consistency.
- B. Assess the client's tissue turgor every day.
- C. Encourage the client to drink carbonated soft drinks.
- D. Weigh the client daily in the same clothes and at the same time.
- E. Assist the client with a warm sitz bath PRN.
Correct Answer: A,B,D,E
Rationale: Monitoring diarrhea, assessing turgor, daily weighing, and sitz baths address dehydration, skin integrity, and comfort. Carbonated drinks may worsen diarrhea.
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The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report?
- A. Abdominal cramping, nausea, and vomiting.
- B. Neuromuscular paralysis and dysphagia.
- C. Gross amounts of explosive bloody diarrhea.
- D. Frequent 'rice water stool' with no fecal odor.
Correct Answer: A
Rationale: Salmonellosis typically causes abdominal cramping, nausea, and vomiting due to bacterial irritation of the GI tract. Paralysis is botulism, bloody diarrhea is more typical of other pathogens, and rice water stool is cholera.
Which problem is most appropriate for the nurse to identify for the client with diarrhea?
- A. Alteration in skin integrity.
- B. Chronic pain perception.
- C. Fluid volume excess.
- D. Ineffective coping.
Correct Answer: A
Rationale: Diarrhea can cause perianal skin breakdown, making alteration in skin integrity the most appropriate problem. Pain is less common, fluid volume is deficient, and coping is secondary.
The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6°F. Which intervention should the nurse implement first?
- A. Notify the health-care provider.
- B. Document the findings in the chart.
- C. Administer an oral antipyretic.
- D. Assess the client's abdomen.
Correct Answer: D
Rationale: Assessing the abdomen first provides critical data on tenderness, rigidity, or rebound, which could indicate complications like perforation, guiding further actions. Notification or medication follows assessment.
The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?
- A. The client's Bernstein esophageal test was positive.
- B. The client's abdominal x-ray shows a hiatal hernia.
- C. The client's WBC count is 14,000/mm3.
- D. The client's hemoglobin is 13.8 g/dL.
Correct Answer: C
Rationale: An elevated WBC count (14,000/mm3) suggests infection or inflammation, which could complicate surgery and requires immediate attention. A positive Bernstein test and hiatal hernia are expected in GERD, and a hemoglobin of 13.8 g/dL is within normal limits.
The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals.
- B. Explain the need to decrease intake of flatus-forming foods.
- C. Teach the client how to perform gentle perianal care.
- D. Encourage the client to attend a support group meeting.
Correct Answer: B
Rationale: Decreasing flatus-forming foods (e.g., beans, broccoli) reduces bloating and discomfort in IBS. Avoiding fluids with meals is not standard, perianal care is secondary, and support groups are psychosocial.