Nokea
The female client diagnosed with anorexia nervosa is admitted to the hospital. The client is 67 inches tall and weighs 40 kg. Which client problem has the highest priority?
- A. Altered nutrition.
- B. Low self-esteem.
- C. Disturbed body image.
- D. Altered sexuality.
Correct Answer: A
Rationale: Altered nutrition is the priority due to severe underweight (BMI ~13.2), risking organ failure and death. Self-esteem, body image, and sexuality are psychosocial and secondary.
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The nurse is taking a hospital admission history of the client. The nurse considers that the client may have IBS when the client makes which statement?
- A. “I am having a lot of bloody diarrhea.”
- B. “I have been vomiting for 2 days.”
- C. “I have lost 10 pounds in the last month.”
- D. “I have noticed mucus in my stools.”
Correct Answer: D
Rationale: A. Clients with IBS may have diarrhea, but it is not bloody. B. Vomiting is not a symptom of IBS. C. Clients with IBS do not have unintentional weight loss. D. Mucus in the stools is a sign of IBS.
A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
- A. Give him an enema one hour before the examination.
- B. Keep him NPO for eight hours before the examination.
- C. Order a low-fat, low-residue diet for breakfast.
- D. Administer enemas until the returns are clear this evening.
Correct Answer: A
Rationale: An enema one hour before sigmoidoscopy clears the sigmoid colon for better visualization.
During a health promotion seminar for senior citizens, a participant asks the nurse to discuss symptoms of gastric cancer. Which statement should be the basis for the nurse’s response?
- A. Cancers that do not penetrate the gastric muscular layer are asymptomatic in the majority of clients.
- B. Pain from early gastric cancer lesions cannot be reduced by over-the-counter (OTC) histamine receptor antagonists.
- C. Unexplained weight gain and increased body mass index (BMI) are early symptoms of gastric cancer.
- D. Anemia is uncommon in gastric cancer, but if it occurs, it is likely due to the effects of aging.
Correct Answer: A
Rationale: A. Eighty percent of clients with early gastric cancer do not have symptoms. B. Pain caused by gastric cancer can be alleviated by OTC histamine receptor antagonists. C. Weight loss and anemia are common symptoms, not weight gain and increased BMI. D. Anemia occurs from malabsorption and nutritional deficiencies, not the effects of aging.
The client is 6 days post—total proctocolectomy with ileostomy creation for ulcerative colitis. The client’s ileostomy is draining large amounts of liquid stool, and the client has dizziness with ambulation. Which parameters should the nurse assess immediately?
- A. Pulse rate for the last 24 hours
- B. Urine output for the last 24 hours
- C. Weight over the last 3 days
- D. Ability to move the lower extremities
- E. Temperature readings for the last 24 hours
Correct Answer: A, B, C, E
Rationale: The nurse should assess for increasing pulse rate over time because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. B. The nurse should assess for decreasing urine output because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. C. The nurse should assess for decreasing weight because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. D. The ability to move the lower extremities is not related to dehydration. E. The nurse should assess the temperature readings because a low-grade temperature is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration.
The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention?
- A. Presence of thin, pink drainage in the Jackson Pratt.
- B. Guarding when the nurse touches the abdomen.
- C. Tenderness around the surgical site during palpation.
- D. Complaints of chills and feeling feverish.
Correct Answer: D
Rationale: Chills and feeling feverish suggest infection, a serious postoperative complication requiring immediate intervention. Thin pink drainage, guarding, and tenderness are expected early post-surgery.