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The client is admitted to a hospital for medical management of acute diverticulitis. The nurse should anticipate that this client’s treatment plan will include which component?
- A. NPO (nothing per mouth) status
- B. Frequent ambulation
- C. Prescribed antibiotics
- D. Antiemetic medication
- E. Deep breathing every 2 hours
Correct Answer: A, C
Rationale: The nurse should plan for the client to be NPO. Medical management for diverticulitis includes resting the bowel. NPO status will help to achieve this. B. Ambulation is not encouraged; resting the body promotes bowel rest. C. Broad-spectrum antibiotics effective against known enteric pathogens are used in treating every stage of diverticulitis. D. Nausea is not a concern with diverticulitis. E. The client did not have surgery; there is no need for deep breathing every 2 hours.
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The nurse writes the problem 'imbalanced nutrition: less than body requirements' for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care?
- A. Provide a high-calorie intake diet.
- B. Discuss total parenteral nutrition (TPN).
- C. Instruct the client to decrease salt intake.
- D. Encourage the client to increase water intake.
Correct Answer: A
Rationale: A high-calorie diet addresses malnutrition and weight loss common in hepatitis, supporting recovery. TPN is invasive, salt restriction is unrelated, and water intake is less critical.
The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication?
- A. It prevents the final transport of hydrogen ions into the gastric lumen.
- B. It blocks receptors controlling hydrochloric acid secretion by the parietal cells.
- C. It protects the ulcer from the destructive action of the digestive enzyme pepsin.
- D. It neutralizes the hydrochloric acid secreted by the stomach.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) inhibit the H+/K+ ATPase pump, preventing hydrogen ion transport into the gastric lumen, thus reducing acid production to promote ulcer healing. Blocking receptors is for H2 antagonists, pepsin protection is for mucosal agents, and neutralization is for antacids.
The occupational health nurse observes the chief financial officer eat large lunch meals. The client disappears into the restroom after a meal for about 20 minutes. Which observation by the nurse would indicate the client has bulimia?
- A. The client jogs two (2) miles a day.
- B. The client has not gained weight.
- C. The client's teeth are a green color.
- D. The client has smooth knuckles.
Correct Answer: B
Rationale: Maintaining normal weight despite large meals and purging (suggested by restroom visits) is characteristic of bulimia. Jogging, green teeth, and smooth knuckles are less specific.
The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?
- A. Reposition the client to promote T-tube drainage
- B. Telephone the surgeon to report these findings
- C. Ask a nursing assistant to obtain a blood pressure
- D. Record the findings and continue to monitor the client
Correct Answer: B
Rationale: A. Repositioning the client might promote bile flow into the T—tube if the client were lying on the tube. However, the jaundice indicates that the problem is internal. B. The T-tube is placed in the common bile duct to ensure patency of the duct. Lack of bile draining into the T—tube and jaundiced sclera are signs of an obstruction to the bile flow. This is most important to report to the surgeon. C. The client’s BP would not be affected by this situation. D. Recording the findings and continuing to monitor the client are inappropriate because the client is experiencing signs of a complication.
The client is complaining of painful swallowing secondary to mouth ulcers. Which statement indicates the nurse's teaching is effective?
- A. I will brush my teeth with a soft-bristle toothbrush.
- B. I will rinse my mouth with Listerine mouthwash.
- C. I will swish with antifungal solution and then swallow.
- D. I will avoid spicy foods, tobacco, and alcohol.
Correct Answer: D
Rationale: Avoiding spicy foods, tobacco, and alcohol reduces irritation of mouth ulcers, indicating effective teaching. Soft brushes help, Listerine may irritate, and antifungal solutions are for candidiasis.