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The client had Billroth II surgery 24 hours ago. The client’s son approaches the nurse in the hallway and asks for information regarding his father’s condition. The wife is listed as the designated contact person. Which nurse response is best?
- A. “What has the surgeon told you about your father’s condition?”
- B. “Let’s both go into your father’s room and ask him how he feels.”
- C. “Let’s go to a more private place to discuss your father’s condition.”
- D. “Let’s review your father’s medical record information together.”
Correct Answer: B
Rationale: A. Discussing client information in a hospital hallway is inappropriate; individuals passing by could overhear confidential client information. B. Going into the client’s room together allows the client to determine if he wants to disclose information and how much information he wants to disclose. C. Even if in a private location, the nurse should not share confidential client information with anyone unless the client has specifically given permission. D. The nurse should not review the medical record of the client with a family member without permission. Some facilities require the client to complete a form requesting permission to review his or her own medical records.
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The nurse is preparing to administer amitriptyline 10 mg orally to the client diagnosed with IBS. The client asks, “Why am I receiving this? I don’t feel depressed.” Which response by the nurse is best?
- A. “The medication is working. People with chronic diseases typically also suffer from depression.”
- B. “People with IBS have difficulty returning to sleep after waking to the bathroom. It will help you get adequate rest.”
- C. “The anticholinergic side effects of the drug will help to prevent bowel irritability and constipation.”
- D. “Tricyclic antidepressants reduce abdominal pain by affecting the communication system from the bowel to the brain.”
Correct Answer: D
Rationale: A. Not all clients with chronic diseases suffer from depression. The response does not address the primary reason for the use of a TCA such as amitriptyline (Elavil) in IBS. B. A common response to TCAs is sedation; however, this medication is not given for this reason. C. TCAs do have anticholinergic side effects and can cause (not prevent) constipation. Clients with IBS can have constipation or diarrhea. D. Evidence supports that TCAs can reduce abdominal pain, and this benefit is unrelated to whether or not the client is being treated for depression.
The client is scheduled for an abdominal-perineal resection for cancer of the rectum. Which components should the nurse include in the client’s preoperative education? Select all that apply.
- A. The enterostomal nurse will be visiting the client prior to surgery.
- B. After surgery rectal suppositories will be given to prevent straining and stress.
- C. The bowel will be cleansed before surgery with a laxative, enema, or whole-gut lavage.
- D. Oral or intravenous (IV) antibiotics will be prescribed to be given preoperatively.
- E. A member of the surgical team will discuss the risk of postoperative sexual dysfunction.
Correct Answer: A,C,D,E
Rationale: An abdominal-perineal resection removes the sigmoid colon, rectum, and anus. As a result the client will have a permanent colostomy. The enterostomal nurse will identify and mark an appropriate stoma location after considering the client’s skinfolds, clothing preferences, and the level of the colostomy. The bowel is cleansed preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Antibiotics are prescribed to be given preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Postoperatively the client with an abdominal-perineal resection is at risk for sexual dysfunction and urinary incontinence as a result of nerve damage. This needs to be discussed with the client prior to surgery by the surgeon or a member of the surgical team.
A client had a barium enema. Following the barium enema, the nurse should anticipate an order for which of the following?
- A. An antacid
- B. A laxative
- C. A muscle relaxant
- D. A sedative
Correct Answer: B
Rationale: Barium is constipating, and a laxative is typically ordered to prevent bowel obstruction post-barium enema.
The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?
- A. I should increase fruits, bran, and fluids in my diet.
- B. I will use warm compresses and take sitz baths daily.
- C. I must take a laxative every night and have a stool daily.
- D. I can use an analgesic ointment or suppository for pain.
Correct Answer: C
Rationale: Daily laxatives are not necessary and may cause dependency; hemorrhoid management focuses on diet and symptom relief. Increased fiber/fluids, sitz baths, and analgesics are correct.
The 36-year-old female client diagnosed with anorexia nervosa tells the nurse 'I am so fat. I won't be able to eat today.' Which response by the nurse is most appropriate?
- A. Can you tell me why you think you are fat?
- B. You are skinny. Many women wish they had your problem.
- C. If you don't eat, we will have to restrain you and feed you.
- D. Not eating might cause physical problems.
Correct Answer: A
Rationale: Asking why the client feels fat explores distorted body image, a therapeutic approach in anorexia. Dismissing feelings, threatening restraints, or stating consequences are nontherapeutic.