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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 client at the eating disorder clinic weighs 35 kg and is 5 ft 7 inches tall. Which would the nurse document as the Body Mass Index (BMI)?
Correct Answer: 11.5
Rationale: BMI = weight (kg) / height (m)^2. Height = 5'7 = 1.73 m. BMI = 35 / (1.73)^2 = 35 / 2.9929 ≈ 11.5.
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 nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD?
- A. Adult-onset asthma.
- B. Pancreatitis.
- C. Peptic ulcer disease.
- D. Increased gastric emptying.
Correct Answer: A
Rationale: GERD is commonly associated with adult-onset asthma due to acid reflux irritating the airways, leading to bronchospasm. Pancreatitis and peptic ulcer disease are less directly linked, and increased gastric emptying is not a typical comorbidity.
Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?
- A. History of side effects experienced from all medications.
- B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Any known allergies to drugs and environmental factors.
- D. Medical histories of at least three (3) generations.
Correct Answer: B
Rationale: NSAID use is a major risk factor for peptic ulcer disease, as these drugs can erode the gastric mucosa. While medication side effects and allergies are relevant, they are less specific, and family history is not a priority in this context.
The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication?
- A. It is administered rectally to help decrease colon inflammation.
- B. This medication slows gastrointestinal (GI) motility and reduces diarrhea.
- C. This medication kills the bacteria causing the exacerbation.
- D. It acts topically on the colon mucosa to decrease inflammation.
Correct Answer: D
Rationale: Sulfasalazine reduces inflammation in IBD by acting topically on the colon mucosa, delivering its active component (mesalamine) to the inflamed areas. It is not primarily an antibiotic, does not slow motility, and is taken orally, not rectally.