Nokea
The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement?
- A. Weigh the client daily and document in the client's chart.
- B. Teach coping strategies such as dietary modifications.
- C. Record the frequency, amount, and color of stools.
- D. Monitor the client's oral fluid intake every shift.
Correct Answer: C
Rationale: Recording stool frequency, amount, and color is critical in acute IBD exacerbation to assess disease activity and guide treatment. Weight and fluid monitoring are important but secondary, and teaching is less urgent during an acute phase.
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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 client asks how he contracted hepatitis A. He reports all of the following. Which one is most likely related to hepatitis A?
- A. He ate home-canned corn.
- B. He ate oysters his roommate brought home from a fishing trip.
- C. He stepped on a nail two weeks ago.
- D. He donated blood two weeks before he got sick.
Correct Answer: B
Rationale: Hepatitis A is transmitted via the fecal-oral route, often through contaminated food like oysters. Oysters from unsafe waters are a common source.
The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge instructions?
- A. I should not eat for at least one (1) day following this procedure.
- B. I can lie down whenever I want after a meal. It won't make a difference.
- C. The stomach contents won't bother my esophagus but will make me nauseous.
- D. I should avoid orange juice and eating tomatoes until my esophagus heals.
Correct Answer: D
Rationale: Avoiding acidic foods like orange juice and tomatoes reduces irritation to the esophagus, indicating understanding of dietary modifications for GERD. Not eating for a day is unnecessary, lying down after meals worsens reflux, and nausea is not the primary concern with GERD.
The client with a diagnosis of rule-out colon cancer is two (2) hours post-sigmoidoscopy procedure. Which assessment data warrant immediate intervention by the nurse?
- A. The client has hyperactive bowel sounds.
- B. The client is eating a hamburger the family brought.
- C. The client is sleepy and wants to sleep.
- D. The client's BP is 96/60 and apical pulse is 108.
Correct Answer: D
Rationale: Low BP (96/60) and tachycardia (pulse 108) suggest hypovolemia or bleeding post-sigmoidoscopy, requiring immediate intervention. Hyperactive bowel sounds, eating, and sleepiness are less urgent.
Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?
- A. The client complains of clear to white sputum.
- B. The client has an episodic blister on the upper lip.
- C. The client complains of a nonhealing sore in the mouth.
- D. The client has bilateral ducts at the second molars.
Correct Answer: C
Rationale: A nonhealing sore in the mouth is concerning for oral cancer, a risk associated with oral tobacco use, requiring immediate assessment. Sputum, blisters, and salivary ducts are less significant.