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The nurse is admitting the client with gastric cancer to an oncology unit for treatment. Which assessment finding should prompt the nurse to review the medical record to determine whether the cancer may have metastasized to the peritoneal cavity?
- A. The client is reporting nausea.
- B. Grey Turner’s sign is present.
- C. The client reports a rapid weight loss.
- D. Ascites is evident in the abdomen.
Correct Answer: D
Rationale: A. Nausea is a sign of gastric outlet obstruction or impending hemorrhage. B. Grey Turner’s sign is a symptom of pancreatitis, not metastasis. C. Weight loss is an initial sign associated with cancer. D. The presence of ascites indicates seeding of the tumor in the peritoneal cavity.
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The occupational health nurse observes the chief financial officer eat large lunch meals. The client disappears into the restroom after a meal for about 20 minutes. Which observation by the nurse would indicate the client has bulimia?
- A. The client jogs two (2) miles a day.
- B. The client has not gained weight.
- C. The client's teeth are a green color.
- D. The client has smooth knuckles.
Correct Answer: B
Rationale: Maintaining normal weight despite large meals and purging (suggested by restroom visits) is characteristic of bulimia. Jogging, green teeth, and smooth knuckles are less specific.
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client's vital signs.
- B. Insert a nasogastric tube.
- C. Begin iced saline lavage.
- D. Start an IV with an 18-gauge needle.
- E. Type and crossmatch for a blood transfusion.
Correct Answer: A, D,B,C,E
Rationale: 1. Assessing vital signs evaluates hemodynamic stability (priority for bleeding). 2. Starting an IV ensures access for fluids/blood. 3. Inserting an NG tube removes blood and assesses bleeding. 4. Iced saline lavage controls bleeding. 5. Type and crossmatch prepares for transfusion.
The nurse writes a psychosocial problem of 'risk for altered sexual functioning related to new colostomy.' Which intervention should the nurse implement?
- A. Tell the client there should be no intimacy for at least three (3) months.
- B. Ensure the client and significant other are able to change the ostomy pouch.
- C. Demonstrate with charts possible sexual positions for the client to assume.
- D. Teach the client to protect the pouch from becoming dislodged during sex.
Correct Answer: D
Rationale: Teaching pouch protection during sex addresses practical concerns, supporting sexual function and confidence. A three-month intimacy ban is unnecessary, pouch changing is unrelated to sexual function, and charts may be less practical.
The client is admitted to the hospital complaining of malaise, abdominal discomfort, and severe diarrhea. The diagnosis is possible Crohn's disease. The client says that he has lost 27 pounds in the last four months even though he has not been dieting. To plan nursing care, which assessment data are most essential for the nurse to obtain?
- A. Approximate number and characteristics of stools each day
- B. Amount of liquid consumed daily
- C. History of previous gastric surgery
- D. Bowel sounds in the right lower quadrant
Correct Answer: A
Rationale: Frequent stools are characteristic of Crohn’s disease, and their number and characteristics are critical for assessing dehydration and skin breakdown risks.
Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy?
- A. Assess the client's neurological status.
- B. Prepare to administer a loop diuretic.
- C. Check the client's stool for blood.
- D. Assess for an abdominal fluid wave.
Correct Answer: A
Rationale: Neurological assessment monitors hepatic encephalopathy progression (e.g., confusion, asterixis), guiding treatment. Diuretics, stool checks, and fluid wave assessments are less specific.