Nokea
The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis?
- A. The client reports up to 20 bloody stools per day.
- B. The client has a feeling of fullness after a heavy meal.
- C. The client has diarrhea alternating with constipation.
- D. The client complains of right lower quadrant pain.
Correct Answer: C
Rationale: Alternating diarrhea and constipation are common in rectosigmoid colon cancer due to partial obstruction by the tumor. Frequent bloody stools are more typical of ulcerative colitis, fullness is nonspecific, and right lower quadrant pain is less likely with rectosigmoid involvement.
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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 client with appendicitis asks the nurse for a laxative to help relieve her constipation. The nurse explains to her that laxatives are not given to persons with possible appendicitis. What is the primary reason for this?
- A. Laxatives will decrease the spread of infection.
- B. Laxatives are not given prior to any type of surgery.
- C. The client does not have true constipation. She only has pressure.
- D. Laxatives could cause a rupture of the appendix.
Correct Answer: D
Rationale: Laxatives increase peristalsis, which could rupture an inflamed appendix, leading to peritonitis.
The home health nurse is performing a follow-up visit for the client diagnosed with chronic hepatitis B. The client is being treated with interferon alpha-2b. Which client comment requires further assessment by the nurse?
- A. “My clothes are tight; I gained 2 pounds this month.”
- B. “Whenever I just bump into anything, I get a bruise.”
- C. “I’ve been staying home and avoiding large crowds.”
- D. “I get tired easily, so I just take my time with things.”
Correct Answer: B
Rationale: A. Anorexia is commonly seen with hepatitis B. A weight gain of 2 lb in one month would typically not be a cause for concern. B. Bruising can indicate thrombocytopenia, which is an adverse effect of treatment. Thrombocytopenia can also occur from liver dysfunction. C. Avoiding large crowds is appropriate; the client will be at increased risk for infection while taking interferon alpha-2b. D. Fatigue is commonly associated with chronic hepatitis B.
The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client?
- A. Tell the client to measure the amount of stool.
- B. Recommend the client come to the clinic immediately.
- C. Explain the client should follow the BRAT diet.
- D. Discuss taking an over-the-counter histamine-2 blocker.
Correct Answer: C
Rationale: The BRAT diet (bananas, rice, applesauce, toast) is bland and helps manage diarrhea. Measuring stool is impractical, immediate clinic visits depend on severity, and H2 blockers are irrelevant.
The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?
- A. Discuss the need to change the abdominal dressing daily.
- B. Tell the client to check the T-tube output every eight (8) hours.
- C. Include the significant other in the discharge teaching.
- D. Instruct the client to stay off clear liquids for two (2) days.
Correct Answer: C
Rationale: Including the significant other ensures support and reinforces discharge teaching for recovery. Daily dressing changes are unnecessary, T-tubes are not used in laparoscopic procedures, and clear liquids are encouraged.