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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.
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The nurse identifies the problem of 'fluid volume deficit' for a client diagnosed with gastritis. Which intervention should be included in the plan of care?
- A. Obtain permission for a blood transfusion.
- B. Prepare the client for total parenteral nutrition.
- C. Monitor the client's lung sounds every shift.
- D. Assess the client's intravenous site.
Correct Answer: D
Rationale: Assessing the IV site ensures proper fluid administration to correct fluid volume deficit in gastritis. Blood transfusion, TPN, and lung sounds are not directly related.
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 admitting the client with gastric cancer to an oncology unit for treatment. Which assessment finding should prompt the nurse to review the medical record to determine whether the cancer may have metastasized to the peritoneal cavity?
- A. The client is reporting nausea.
- B. Grey Turner’s sign is present.
- C. The client reports a rapid weight loss.
- D. Ascites is evident in the abdomen.
Correct Answer: D
Rationale: A. Nausea is a sign of gastric outlet obstruction or impending hemorrhage. B. Grey Turner’s sign is a symptom of pancreatitis, not metastasis. C. Weight loss is an initial sign associated with cancer. D. The presence of ascites indicates seeding of the tumor in the peritoneal cavity.
The nurse is caring for the client with a Zenker’s diverticulum. Which problem should be the nurse’s priority?
- A. Pain related to heartburn from gastric reflux.
- B. Aspiration related to regurgitation of food accumulated in the diverticula.
- C. Constipation related to anatomical changes of the sigmoid colon.
- D. Altered nutrition, less than body requirements related to dysphagia.
Correct Answer: B
Rationale: A. The client may have difficulty with heartburn, but this does not take priority over aspiration. B. Zenker’s diverticulum is an outpouching of the esophagus near the hypopharyngeal sphincter. Food can become trapped in the diverticula and cause aspiration. C. Constipation is not a concern with Zenker’s diverticulum. D. The client may have weight loss, but this does not take priority over aspiration.
After Billroth II surgery (gastrojejunostomy), the client experiences weakness, diaphoresis, anxiety, and palpitations 2 hours after a high-carbohydrate meal. The nurse should interpret that these symptoms indicate the development of which problem?
- A. Steatorrhea
- B. Duodenal reflux
- C. Hypervolemic fluid overload
- D. Postprandial hypoglycemia
Correct Answer: D
Rationale: A. Although steatorrhea may occur after gastric resection, the symptoms of steatorrhea include fatty stools with a foul odor, not these symptoms. B. The symptoms of duodenal reflux are abdominal pain and vomiting, not these symptoms. Duodenal reflux is not associated with food intake. C. Symptoms of fluid overload would include increased BP, edema, and weight gain, not these symptoms. D. When eating large amounts of carbohydrates at a meal, the rapid glucose absorption from the chime results in hyperglycemia. This elevated glucose stimulates insulin production, which then causes an abrupt lowering of the blood glucose level. Hypoglycemic symptoms of weakness, diaphoresis, anxiety, and palpitations occur.