Nokea
The client with Crohn’s disease has undergone a barium enema that showed strictures in the ileum. Based on this finding, the nurse should monitor the client closely for signs of which complication?
- A. Peritonitis
- B. Obstruction
- C. Malabsorption
- D. Fluid imbalance
Correct Answer: B
Rationale: A. Peritonitis would not be an expected consequence of a bowel stricture. B. The nurse should monitor for signs of a bowel obstruction. Bowel strictures are a common complication of Crohn’s disease and can result in an acute bowel obstruction. C. Malabsorption would not be an expected consequence of a bowel stricture. D. Fluid balance would be affected once total obstruction develops.
You may also like to solve these questions
The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first?
- A. Mark the drainage on the dressing with the time and date.
- B. Change the dressing immediately using sterile technique.
- C. Notify the health-care provider immediately.
- D. Reinforce the dressing with a sterile gauze pad.
Correct Answer: C
Rationale: Dark reddish brown drainage one day post-surgery suggests possible bleeding or dehiscence, warranting immediate notification of the HCP for evaluation. Marking or reinforcing the dressing delays action, and changing the dressing is secondary.
Which instruction should be discussed with the client diagnosed with gastroesophageal reflux disease (GERD)?
- A. Eat a low-carbohydrate, low-sodium diet.
- B. Lie down for 30 minutes after eating.
- C. Do not eat spicy foods or acidic foods.
- D. Drink two (2) glasses of water before bedtime.
Correct Answer: C
Rationale: Avoiding spicy and acidic foods reduces esophageal irritation, a key instruction for managing GERD. Low-carb/sodium diets are not specific, lying down after eating worsens reflux, and water before bedtime is irrelevant.
The nurse is assigned to care for four clients. The nurse should plan to assess which client first?
- A. The client with ascites who is having mild dyspnea with activity
- B. The client with a peptic ulcer who now has severe vomiting
- C. The client who had a colonoscopy and is having diarrheal stools
- D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes
Correct Answer: D
Rationale: D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes should be attended to first. Generalized rash indicates an allergic reaction. This could develop into an anaphylactic reaction. B. The client with a peptic ulcer who now has severe vomiting should be attended to second. Vomiting in PUD may indicate a complication such as mechanical obstruction from scarring. C. The client who had a colonoscopy and is having diarrheal stools should be attended to third. Diarrhea may have been the indication for the client’s colonoscopy or a side effect of the bowel prep. A. The client with ascites who is having mild dyspnea with activity can be attended to last. The dyspnea is usually due to the enlarged abdomen.
A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis?
- A. I am a vegetarian.'
- B. My mother and grandmother have diabetes.'
- C. I take aspirin several times a day for tension headaches.'
- D. I take multivitamin and iron tablets every day.'
Correct Answer: C
Rationale: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Vegetarianism, family history of diabetes, and multivitamins with iron are not directly linked to duodenal ulcers.
The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement?
- A. Document the findings as normal.
- B. Assess the client's bowel sounds.
- C. Determine the client's last bowel movement.
- D. Insert the NG tube at least two (2) more inches.
Correct Answer: A
Rationale: Green bile drainage from an NG tube is normal, indicating proper placement and function, so documenting this is appropriate. Further insertion or other assessments are unnecessary unless other symptoms arise.