Nokea
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.
You may also like to solve these questions
The nurse caring for a client diagnosed with GERD writes the client problem of 'behavior modification.' Which intervention should be included for this problem?
- A. Teach the client to sleep with a foam wedge under the head.
- B. Encourage the client to decrease the amount of smoking.
- C. Instruct the client to take over-the-counter medication for relief of pain.
- D. Discuss the need to attend Alcoholics Anonymous to quit drinking.
Correct Answer: A
Rationale: Sleeping with a foam wedge elevates the head, reducing reflux by preventing stomach acid from flowing into the esophagus during sleep, a key behavioral modification for GERD. Smoking cessation is beneficial but less specific to immediate symptom relief, and the other options are not directly related to behavior modification for GERD.
The day after surgery in which a colostomy was performed, the client says, 'I know the doctor did not really do a colostomy.' The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time?
- A. Agree with the client until the client is ready to accept the colostomy
- B. Say, 'It must be difficult to have this kind of surgery.'
- C. Force the client to look at his colostomy
- D. Ask the surgeon to explain the surgery to the client
Correct Answer: B
Rationale: Acknowledging the difficulty of the surgery supports the client emotionally during the denial stage without forcing confrontation.
Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning?
- A. Fluid volume deficit.
- B. Nausea.
- C. Risk for aspiration.
- D. Impaired urinary elimination.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly patients with gastroenteritis, as dehydration from vomiting and diarrhea poses significant risks. Nausea, aspiration, and urinary issues are secondary.
The nurse is reviewing the history and physical of a teenager admitted to a hospital with a diagnosis of ulcerative colitis. Based on this diagnosis, which information should the nurse expect to see on this client’s medical record?
- A. Heartburn and regurgitation
- B. Abdominal pain and bloody diarrhea
- C. Weight gain and elevated blood glucose
- D. Abdominal distention and hypoactive bowel sounds
Correct Answer: B
Rationale: A. Heartburn and regurgitation are not symptoms of ulcerative colitis. B. The nurse should expect to read about the primary symptoms of ulcerative colitis, which are bloody diarrhea and abdominal pain. C. Weight loss, not weight gain, often occurs in severe cases of ulcerative colitis. D. Bowel sounds are often hyperactive rather than hypoactive in ulcerative colitis.
The client diagnosed with IBD is prescribed total parenteral nutrition (TPN). Which intervention should the nurse implement?
- A. Check the client's glucose level.
- B. Administer an oral hypoglycemic.
- C. Assess the peripheral intravenous site.
- D. Monitor the client's oral food intake.
Correct Answer: A
Rationale: TPN, high in dextrose, can cause hyperglycemia, so monitoring glucose levels is essential, especially in IBD patients with potential metabolic stress. Oral hypoglycemics are inappropriate, TPN uses central lines, and oral intake is typically minimal.