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.
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The nurse writes the problem 'imbalanced nutrition: less than body requirements' for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care?
- A. Provide a high-calorie intake diet.
- B. Discuss total parenteral nutrition (TPN).
- C. Instruct the client to decrease salt intake.
- D. Encourage the client to increase water intake.
Correct Answer: A
Rationale: A high-calorie diet addresses malnutrition and weight loss common in hepatitis, supporting recovery. TPN is invasive, salt restriction is unrelated, and water intake is less critical.
A distal pancreatectomy and splenectomy is performed on a client with cancer of the pancreas. He is returned to his room postoperatively. The client is sleepy but can answer simple questions appropriately. His dressing is dry and intact. Vital signs are within normal limits. Which of the following nursing measures must be done before the nurse leaves the room?
- A. Inform his wife that he has returned to his room.
- B. Check to see if the indwelling urinary catheter bag is correctly attached to the bed frame.
- C. Assess to be sure he is not experiencing any discomfort.
- D. Put all four side rails in the high position.
Correct Answer: D
Rationale: Raising all four side rails ensures safety for a sleepy postoperative client, preventing falls.
The male client tells the nurse he has been experiencing 'heartburn' at night that awakens him. Which assessment question should the nurse ask?
- A. How much weight have you gained recently?
- B. What have you done to alleviate the heartburn?
- C. Do you consume many milk and dairy products?
- D. Have you been around anyone with a stomach virus?
Correct Answer: B
Rationale: Asking what the client has done to alleviate the heartburn helps the nurse understand the severity, triggers, and any self-management strategies, which are critical for assessing GERD. Weight gain, dairy consumption, or exposure to a stomach virus are less directly related to the immediate assessment of heartburn symptoms.
The client is admitted to the hospital complaining of malaise, abdominal discomfort, and severe diarrhea. The diagnosis is possible Crohn's disease. The client says that he has lost 27 pounds in the last four months even though he has not been dieting. To plan nursing care, which assessment data are most essential for the nurse to obtain?
- A. Approximate number and characteristics of stools each day
- B. Amount of liquid consumed daily
- C. History of previous gastric surgery
- D. Bowel sounds in the right lower quadrant
Correct Answer: A
Rationale: Frequent stools are characteristic of Crohn’s disease, and their number and characteristics are critical for assessing dehydration and skin breakdown risks.
The client who has had a hemorrhoidectomy wants to know why she cannot take a sitz bath immediately upon return from the operating room. The nurse's response is based on which of the following concepts?
- A. Heat can stimulate bowel movement too quickly after surgery.
- B. Clients are generally not awake enough for several hours to safely take sitz baths.
- C. Heat applied immediately postoperatively increases the possibility of hemorrhage.
- D. Sitting in water before the sutures are removed may cause infection.
Correct Answer: C
Rationale: Heat increases blood flow, raising the risk of hemorrhage immediately post-hemorrhoidectomy.