Nokea
The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving?
- A. The client is using more pain medication on a daily basis.
- B. The client's nasogastric tube is draining coffee-ground material.
- C. The client has a decrease in temperature and a soft abdomen.
- D. The client has had two (2) soft-formed bowel movements.
Correct Answer: C
Rationale: A decrease in temperature and a soft abdomen indicate resolving infection and inflammation in peritonitis. Increased pain medication, coffee-ground drainage, and bowel movements are not improvement signs.
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The client with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement. The nurse realizes the client does not understand the procedure when the client makes which statement?
- A. “I hope the abdominal incision heals fast after this procedure so I can return home.”
- B. “My risk of bleeding from my esophagus again should be decreased after this procedure.”
- C. “The shunt they are placing could become occluded in the future; I hope it doesn’t happen.”
- D. “This procedure should keep me from getting so much fluid buildup in my abdomen.”
Correct Answer: A
Rationale: A. This statement indicates the client does not understand the procedure. There is no need for an abdominal incision. The TIPS is placed through the jugular vein and threaded down to the hepatic vein. B. The TIPS procedure will decrease pressure in the portal vein and thus decrease the risk of bleeding from esophageal varices. C. There is a risk that the stent that is placed will become occluded. D. The shunt will decrease ascites formation.
Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism?
- A. Make sure all hamburger meat is well cooked.
- B. Ensure all dairy products are refrigerated.
- C. Discuss why campers should drink only bottled water.
- D. Discard damaged canned goods.
Correct Answer: D
Rationale: Clostridium botulinum thrives in improperly canned foods, so discarding damaged cans prevents botulism. Cooking meat, refrigerating dairy, and bottled water are unrelated to botulism.
The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.
The nurse is assessing the integumentary system of the client diagnosed with anorexia nervosa. Which finding supports the diagnosis?
- A. Preoccupation with calories.
- B. Thick body hair.
- C. Sore tongue.
- D. Dry, brittle hair.
Correct Answer: D
Rationale: Dry, brittle hair is a common integumentary finding in anorexia nervosa due to malnutrition. Preoccupation is psychological, thick hair is unrelated, and sore tongue is less specific.
The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?
- A. Assess the gag reflex every shift.
- B. Stay with the client at all times.
- C. Administer the laxative lactulose (Chronulac).
- D. Monitor the client's ammonia level.
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can dislodge or cause complications like aspiration, requiring constant monitoring. Gag reflex, lactulose, and ammonia are unrelated to this intervention.