Nokea
The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase?
- A. Clay-colored stools and jaundice.
- B. Normal appetite and pruritus.
- C. Being afebrile and left upper quadrant pain.
- D. Complaints of fatigue and diarrhea.
Correct Answer: D
Rationale: The preicteric phase of hepatitis involves nonspecific symptoms like fatigue and diarrhea before jaundice appears. Clay-colored stools, jaundice, and pruritus occur in the icteric phase.
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The nurse is taking a hospital admission history of the client. The nurse considers that the client may have IBS when the client makes which statement?
- A. “I am having a lot of bloody diarrhea.”
- B. “I have been vomiting for 2 days.”
- C. “I have lost 10 pounds in the last month.”
- D. “I have noticed mucus in my stools.”
Correct Answer: D
Rationale: A. Clients with IBS may have diarrhea, but it is not bloody. B. Vomiting is not a symptom of IBS. C. Clients with IBS do not have unintentional weight loss. D. Mucus in the stools is a sign of IBS.
A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.
The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement?
- A. Provide meticulous skin care to stoma.
- B. Assess the flank incision.
- C. Maintain the indwelling catheter.
- D. Irrigate the (JP) drains every shift.
- E. Position the client semirecumbent.
Correct Answer: A,C,E
Rationale: Stoma skin care prevents irritation, an indwelling catheter is maintained post-surgery to monitor output, and a semirecumbent position aids breathing and comfort. Flank incisions are not typical, and JP drains are not irrigated.
A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
- A. Give him an enema one hour before the examination.
- B. Keep him NPO for eight hours before the examination.
- C. Order a low-fat, low-residue diet for breakfast.
- D. Administer enemas until the returns are clear this evening.
Correct Answer: A
Rationale: An enema one hour before sigmoidoscopy clears the sigmoid colon for better visualization.
The nurse is caring for the client who had a vertical banded gastroplasty. The nurse teaches that nausea can occur after this surgery from which situation?
- A. The stomach pouch becomes overfilled.
- B. The lower half of the stomach becomes spastic.
- C. The duodenum incision becomes inflamed.
- D. The dumping syndrome from a high-protein meal.
Correct Answer: A
Rationale: A. A small pouch (15—20 mL capacity) is constructed in the upper part of the stomach during vertical banded gastroplasty. Overfilling of this pouch stimulates afferent nerve fibers, which relay information to the chemoreceptor trigger zone in the brain, causing nausea. B. The function of the lower half of the stomach is not affected with a vertical banded gastroplasty. C. The duodenum is not incised during a vertical banded gastroplasty. D. Dumping syndrome is more likely to occur from a meal high in simple carbohydrates, not protein.