Nokea
The nurse identifies the client problem 'alteration in gastrointestinal system' for the elderly client. Which statement reflects the most appropriate rationale for this problem?
- A. Elderly clients have the ability to chew food more thoroughly with dentures.
- B. Elderly clients have an increase in digestive enzymes, which helps with digestion.
- C. Elderly clients have an increased need for laxatives because of a decrease in bile.
- D. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.
Correct Answer: C
Rationale: Elderly clients often have reduced peristalsis and bile production, leading to constipation and increased laxative need, supporting the GI alteration problem. Dentures, enzyme increase, and bacterial overgrowth are less accurate.
You may also like to solve these questions
The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse?
- A. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
- B. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning.
- C. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.
- D. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.
Correct Answer: C
Rationale: The client with GERD and wheezing in all five lobes indicates potential respiratory complications, possibly asthma or aspiration, requiring complex assessment and management best suited for the experienced nurse. The other clients have less acute or complex needs.
A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.
The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply.
- A. Tell the client not to eat or drink.
- B. Start an intravenous line.
- C. Assess the client for abdominal tenderness.
- D. Have the dietitian consult for a low-residue diet.
- E. Place the client on bedrest with bathroom privileges.
Correct Answer: A,B,C,E
Rationale: NPO status, IV line, abdominal assessment, and bedrest manage acute diverticulitis by resting the bowel and monitoring complications. Low-residue diets are for stable phases.
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
- A. To immobilize the diaphragm
- B. To facilitate full chest expansion
- C. To minimize the danger of aspiration
- D. To reduce the likelihood of bleeding
Correct Answer: D
Rationale: Right-side positioning with a pillow applies pressure to the biopsy site, reducing the risk of bleeding.
The nurse is caring for the client with acute cholecystitis. The nurse anticipates that conservative treatment will include which component?
- A. Providing a low-texture bland diet
- B. Giving anticholinergic medications
- C. Positioning so the head of the bed is flat
- D. Administering laxatives to clear the bowel
Correct Answer: B
Rationale: A. The client should be NPO rather than be given a bland diet to decrease gallbladder stimulation. B. The nurse should anticipate giving anticholinergic medications to decrease secretions and counteract smooth muscle spasms. C. The client should be positioned with the head of the bed elevated (not flat) to decrease the pressure of the abdominal contents on the diaphragm and to improve ventilation. D. Laxatives would increase GI stimulation unnecessarily.