Nokea
The nurse completes discharge teaching for the client after a small bowel resection for Crohn’s disease. The nurse determines that more education is needed when overhearing which statement made by the client to the client’s spouse?
- A. “I’m so glad I’ll never need surgery again for Crohn’s disease.”
- B. “I’ll need to get a new scale so I can continue to monitor my weight.”
- C. “I’ll likely need to be on hydrocortisone if an exacerbation occurs.”
- D. “I will probably have to take vitamin supplements all of my life.”
Correct Answer: A
Rationale: A. The nurse should determine that the client needs additional education with this statement. Crohn’s disease can occur throughout the GI tract. Surgery in one area of the GI tract will not prevent the disease from recurring in another area. This recurrence can result in the need for further surgery. B. Clients with Crohn’s disease will always need to monitor their weight. C. Most likely, the client will need some type of glucocorticoid medication such as hydrocortisone to treat a future exacerbation. D. Clients will need vitamins to maintain adequate nutrient levels, since inflamed areas of the GI tract do not absorb nutrients well.
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The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective?
- A. I will take my lipid-lowering medicine at the same time each night.
- B. I may experience some discomfort when I eat a high-fat meal.
- C. I need someone to stay with me for about a week after surgery.
- D. I should not splint my incision when I deep breathe and cough.
Correct Answer: B
Rationale: High-fat meals may cause discomfort post-cholecystectomy due to altered bile flow, indicating understanding of dietary adjustments. Lipid-lowering drugs, prolonged supervision, and avoiding splinting are incorrect.
The nurse identifies the client problem 'excess fluid volume' for the client in liver failure. Which short-term goal would be most appropriate for this problem?
- A. The client will not gain more than two (2) kg a day.
- B. The client will have no increase in abdominal girth.
- C. The client's vital signs will remain within normal limits.
- D. The client will receive a low-sodium diet.
Correct Answer: B
Rationale: No increase in abdominal girth indicates stable ascites, directly addressing excess fluid volume. Weight gain limits, vital signs, and diet are related but less specific.
The nurse is taking a hospital admission history for the 40-year-old client. The nurse is concerned about possible acute pancreatitis when the client makes which statement?
- A. “I have sudden-onset intense pain in my upper left abdomen that goes to my back.”
- B. “I had persistent lower abdominal pain that now shifted to the lower right quadrant.”
- C. “My stools are loose and bloody, and I have cramping abdominal pain with spasms.”
- D. “I have this mild pain in my upper abdomen, but I have been vomiting forcefully a lot.”
Correct Answer: A
Rationale: A. The predominant symptom of acute pancreatitis is severe, deep or piercing, continuous or steady abdominal pain in the upper left quadrant. The pain may radiate to the back because of the retroperitoneal location of the pancreas. Middle-aged individuals are at increased risk for developing acute pancreatitis. B. Abdominal pain located mainly in the right lower quadrant may be a symptom of appendicitis (not pancreatitis). Appendicitis is more common in younger adults. C. Bloody diarrhea and colicky abdominal pain are symptoms of IBD, also more common in young adults. D. Upper abdominal pain and projectile vomiting are symptoms of gastric outlet obstruction or another GI disorder and not pancreatitis.
Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?
- A. Administer an antiemetic 30 minutes before the meal.
- B. Provide mouth care with lemon-glycerin swabs prior to the meal.
- C. Create a social atmosphere by interacting with the client.
- D. Encourage the client's parents to sit with the client during meals.
Correct Answer: D
Rationale: Encouraging parents to sit with the client is within the UAP’s scope and promotes a supportive eating environment. Administering medication, mouth care, and creating a social atmosphere require RN skills or specific training.
Following a hemorrhoidectomy, the nurse assesses the client's voiding. What is the reason for this concern?
- A. The client has been NPO before and during surgery.
- B. Urinary retention is frequently seen after a hemorrhoidectomy.
- C. The client has a long history of hemorrhoids, making her prone to voiding problems.
- D. The client had several pregnancies, which can make voiding difficult.
Correct Answer: B
Rationale: Urinary retention is common post-hemorrhoidectomy due to pain and swelling affecting pelvic nerves.