Nokea
The nurse is assessing a 71-year-old female client with ulcerative colitis. Which assessment finding related to the family will have the greatest impact on the client's rehabilitation after discharge?
- A. The family's ability to take care of the client's special diet needs
- B. The family's expectation that the client will resume responsibilities and role-related activities
- C. Emotional support from the family
- D. The family's ability to understand the ups and downs of the illness
Correct Answer: C
Rationale: The correct answer is C because emotional support from the family is crucial for the client's rehabilitation. Emotional support can positively impact the client's mental health, motivation, and adherence to treatment plans. It can also reduce stress and anxiety, which are common in chronic illnesses like ulcerative colitis. Options A and D focus on practical aspects and understanding of the illness, which are important but not as impactful as emotional support. Option B addresses the client's responsibilities, which, while important, may not have as direct an impact on rehabilitation as emotional support.
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A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
- A. Notify the physician.
- B. Change the dressing.
- C. Circle the amount on the dressing with a pen.
- D. Continue to monitor the drainage.
Correct Answer: B
Rationale: The correct answer is B: Change the dressing. This is the most appropriate intervention because serosanguineous drainage can indicate the need for a dressing change to prevent infection and ensure proper wound healing. Changing the dressing will also allow for better assessment of the drainage and the incision site.
A: Notifying the physician may not be necessary at this stage since serosanguineous drainage is expected in the early postoperative period.
C: Circling the amount on the dressing with a pen does not address the need for a dressing change or further assessment of the drainage.
D: Continuing to monitor the drainage is important, but changing the dressing is the immediate action needed to ensure proper wound care.
A nurse is developing a teaching plan for the client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session?
- A. Activity should be limited to prevent fatigue
- B. The diet should be low in calories
- C. Meals should be large to conserve energy
- D. Alcohol intake should be limited to 2 oz. per day.
Correct Answer: A
Rationale: The correct answer is A. For a client with viral hepatitis, limiting activity helps prevent fatigue and aids in recovery. Excessive activity can worsen symptoms. Choice B is incorrect because a low-calorie diet may not provide enough nutrients for the body to fight the infection. Choice C is incorrect as large meals can strain the liver and worsen symptoms. Choice D is incorrect as any alcohol intake can further damage the liver in viral hepatitis. In summary, choice A is correct as it promotes rest and aids recovery, while the other choices can potentially worsen the condition.
The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the client's plan of care?
- A. Encourage regular use of antidiarrheal medications.
- B. Incorporate frequent rest periods into the client's schedule.
- C. Have the client maintain a high-fiber diet.
- D. Wear a gown when providing direct client care.
Correct Answer: B
Rationale: The correct answer is B: Incorporate frequent rest periods into the client's schedule. Rest periods are essential for managing ulcerative colitis exacerbations as they help reduce stress on the digestive system. Antidiarrheal medications (A) may worsen the condition by masking symptoms and delaying appropriate treatment. High-fiber diets (C) can aggravate symptoms in some individuals with ulcerative colitis. Wearing a gown (D) is unrelated to managing ulcerative colitis exacerbations.
The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
- A. Yogurt
- B. Broccoli
- C. Cucumbers
- D. Eggs
Correct Answer: A
Rationale: The correct answer is A: Yogurt. Yogurt contains probiotics that help maintain a healthy balance of gut bacteria, which can reduce the odor of stool in the ostomy drainage bag. Probiotics can also improve digestion and overall gut health. Broccoli (B) and eggs (D) can actually contribute to stronger odors due to their sulfur content. Cucumbers (C) are low in fiber and may not have a significant impact on stool odor.
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?
- A. Leukopenia with a shift to the right
- B. Leukocytosis with a shift to the right
- C. Leukocytosis with a shift to the left
- D. Leukopenia with a shift to the left
Correct Answer: C
Rationale: The correct answer is C: Leukocytosis with a shift to the left. In acute appendicitis, the body responds with an increase in white blood cells (leukocytosis) as a sign of infection. A shift to the left indicates an increase in immature neutrophils, which is a common response to acute bacterial infections like appendicitis. Leukopenia (choices A and D) would not be expected in appendicitis. Leukopenia is a decrease in white blood cells, which is not typical in an acute infection like appendicitis. Leukocytosis with a shift to the right (choice B) could be seen in chronic infections or conditions like leukemia, not in acute appendicitis where a shift to the left is more common due to the rapid response to infection.