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The client with appendicitis asks the nurse for a laxative to help relieve her constipation. The nurse explains to her that laxatives are not given to persons with possible appendicitis. What is the primary reason for this?
- A. Laxatives will decrease the spread of infection.
- B. Laxatives are not given prior to any type of surgery.
- C. The client does not have true constipation. She only has pressure.
- D. Laxatives could cause a rupture of the appendix.
Correct Answer: D
Rationale: Laxatives increase peristalsis, which could rupture an inflamed appendix, leading to peritonitis.
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During a clinic visit the client provides all of the following health history information. Which client statement should be most concerning to the nurse because it could describe a symptom of esophageal cancer?
- A. “I have been having a lot of indigestion lately.”
- B. “When I eat meat, it seems to get stuck halfway down.”
- C. “I have been waking up at night lately with chest pain.”
- D. “I gained weight, even though I have not changed my diet.”
Correct Answer: B
Rationale: A. Indigestion is not a symptom of esophageal cancer. B. Progressive dysphagia is the most common symptom associated with esophageal cancer, and it is initially experienced when eating meat. It is often described as a feeling that food is not passing. C. Chest pain is not a symptom of esophageal cancer. D. Weight loss rather than gain is a symptom of esophageal cancer.
The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication every day and prn.
- B. Perform bowel training every two (2) hours.
- C. Administer an oil retention enema.
- D. Prepare for an upper gastrointestinal (UGI) series x-ray.
Correct Answer: C
Rationale: An oil retention enema softens and facilitates removal of impacted stool. Antidiarrheals are contraindicated, bowel training is long-term, and UGI is irrelevant.
The nurse assesses the client previously diagnosed as having an inguinal hernia. The nurse considers that the client’s hernia may be strangulated when which assessment findings are noted?
- A. Abdominal distention
- B. Dyspnea with exertion
- C. Severe abdominal pain
- D. No stool for the past week
- E. Hyperactive bowel sounds
Correct Answer: A, C, D
Rationale: Abdominal distention occurs because the bowel is obstructed when the hernia is strangulated. B. Dyspnea with exertion is not associated with strangulation of an inguinal hernia. C. Lack of blood supply from strangulation causes severe abdominal pain. D. A bowel obstruction prevents the passage of stool. E. Bowel sounds with strangulation and bowel obstruction would be hypoactive or absent, not hyperactive.
The client has diarrhea that has been cultured positive for Clostridium difficile (C. diff). In order to prevent the spread of infection, the nurse should perform which intervention?
- A. Wear an isolation gown, gloves, and mask when providing care.
- B. Perform vigorous hand hygiene using only soap and water.
- C. Place the client in a private room with negative pressure airflow.
- D. Instruct visitors to use the alcohol-based hand wash for self-protection.
Correct Answer: B
Rationale: A. The nurse does not need to wear a mask when caring for the client; the bacterium is transmitted through direct contact. B. Hand washing with soap and water is performed instead of using alcohol—based hand cleaners; alcohol-based cleaners lack sporicidal activity. Even vigorous scrubbing with soap and water does not kill all of the spores. C. The client should be in a private room but does not need a negative pressure room. Negative pressure rooms are used with airborne diseases. D. The spores of C. diff can survive on inanimate objects such as tables and bedrails. For self-protection, visitors should be instructed to wash vigorously with soap and water and not to use the alcohol-based hand wash.
The nurse is caring for a client diagnosed with ulcerative colitis. Which symptom(s) support this diagnosis?
- A. Increased appetite and thirst.
- B. Elevated hemoglobin.
- C. Multiple bloody, liquid stools.
- D. Exacerbations unrelated to stress.
Correct Answer: C
Rationale: Multiple bloody, liquid stools are a hallmark of ulcerative colitis due to mucosal inflammation. Appetite/thirst increase, elevated hemoglobin, and stress-unrelated exacerbations are incorrect.