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 assessing the integumentary system of the client diagnosed with anorexia nervosa. Which finding supports the diagnosis?
- A. Preoccupation with calories.
- B. Thick body hair.
- C. Sore tongue.
- D. Dry, brittle hair.
Correct Answer: D
Rationale: Dry, brittle hair is a common integumentary finding in anorexia nervosa due to malnutrition. Preoccupation is psychological, thick hair is unrelated, and sore tongue is less specific.
The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue?
- A. Cheeseburger and milk shake.
- B. Canned peaches and a sandwich on whole-wheat bread.
- C. Mashed potatoes and mechanically ground red meat.
- D. Biscuits and gravy with bacon.
Correct Answer: C
Rationale: Mashed potatoes and ground meat are soft, low-fiber, and digestible, suitable for immobile clients to prevent constipation. Burgers, whole-wheat, and fatty foods are harder to digest.
The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis?
- A. My pain goes away when I have a bowel movement.
- B. I have bright red blood in my stool all the time.
- C. I have episodes of diarrhea and constipation.
- D. My abdomen is hard and rigid and I have a fever.
Correct Answer: C
Rationale: Crohn's disease often causes alternating diarrhea and constipation due to inflammation and strictures throughout the GI tract. Pain relief after bowel movements is less specific, bright red blood is more typical of ulcerative colitis, and a rigid abdomen suggests complications.
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 client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next?
- A. Call the HCP and suggest he or she talk with the client.
- B. Determine what about the HCP is bothering the client.
- C. Notify the nursing supervisor to arrange a new HCP to take over.
- D. Explain the client cannot request another HCP until after discharge.
Correct Answer: B
Rationale: Determining the specific issue allows the nurse to address the concern effectively, whether through communication, advocacy, or escalation. Contacting the HCP or supervisor prematurely or dismissing the client’s request is less appropriate.