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The client with hepatitis asks the nurse, 'I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?' Which statement is the nurse's best response?
- A. You are concerned about taking an herb.
- B. The herb has been used to treat liver disease.
- C. I would not take anything that is not prescribed.
- D. Why would you want to take any herbs?
Correct Answer: B
Rationale: Milk thistle is commonly used for liver support and may have hepatoprotective effects, though evidence is limited. This response provides accurate information without dismissing the client’s query.
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The client is scheduled for an abdominal-perineal resection for cancer of the rectum. Which components should the nurse include in the client’s preoperative education? Select all that apply.
- A. The enterostomal nurse will be visiting the client prior to surgery.
- B. After surgery rectal suppositories will be given to prevent straining and stress.
- C. The bowel will be cleansed before surgery with a laxative, enema, or whole-gut lavage.
- D. Oral or intravenous (IV) antibiotics will be prescribed to be given preoperatively.
- E. A member of the surgical team will discuss the risk of postoperative sexual dysfunction.
Correct Answer: A,C,D,E
Rationale: An abdominal-perineal resection removes the sigmoid colon, rectum, and anus. As a result the client will have a permanent colostomy. The enterostomal nurse will identify and mark an appropriate stoma location after considering the client’s skinfolds, clothing preferences, and the level of the colostomy. The bowel is cleansed preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Antibiotics are prescribed to be given preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Postoperatively the client with an abdominal-perineal resection is at risk for sexual dysfunction and urinary incontinence as a result of nerve damage. This needs to be discussed with the client prior to surgery by the surgeon or a member of the surgical team.
The nurse is completing the client’s hospital admission history. Which statement should prompt the nurse to further question the client about symptoms associated with GERD?
- A. “I have been experiencing headaches immediately after eating.”
- B. “Lately, I wake up at night with a burning feeling in my chest.”
- C. “I have been waking up at night sweating and wet all over.”
- D. “Immediately after eating I feel sleepy and want to go to bed.”
Correct Answer: B
Rationale: A. Headaches are a symptom not related to GERD. B. Heartburn, which is described as a burning, tight sensation in the lower sternum, is the most common symptom of GERD. It will often wake the client from sleep. C. Night sweats are a symptom not related to GERD. D. Postprandial sleepiness is a symptom not related to GERD.
The nurse writes the problem 'risk for impaired skin integrity' for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?
- A. The client will have intact skin around the stoma.
- B. The client will be able to change the ostomy bag.
- C. The client will express anxiety about the body changes.
- D. The client will maintain fluid balance.
Correct Answer: A
Rationale: Intact skin around the stoma directly addresses the risk for impaired skin integrity due to colostomy leakage or irritation. Other outcomes are unrelated or secondary.
The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which healthcare provider's order should the nurse question?
- A. Insert a nasogastric tube.
- B. Start an IV with D5W at 125 mL/hr.
- C. Put the client on a clear liquid diet.
- D. Place the client on bedrest with bathroom privileges.
Correct Answer: A
Rationale: An NG tube is not routinely needed for acute diverticulitis unless there is vomiting or obstruction, which is not indicated. IV fluids, clear liquids, and bedrest are standard to rest the bowel and manage inflammation.
Which interventions should the nurse discuss regarding prevention of an acute exacerbation of diverticulosis? Select all that apply.
- A. Eat a low-fiber diet.
- B. Drink 2,500 mL of water daily.
- C. Avoid eating foods with seeds.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: B,C,D
Rationale: High fluid intake (2,500 mL), avoiding seeds, and exercise (walking) prevent constipation and reduce diverticulitis risk. Low-fiber diets worsen diverticulosis, and antacids are irrelevant.