Nokea
The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
- A. The sclera
- B. The gums
- C. The hands
- D. The nails
- E. The hard palate
- F. The conjunctiva
Correct Answer: A,B,E,F
Rationale: In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
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A nurse is employed as a gastroenterologist's office nurse. When assessing the client, which objective data would provide useful information for diagnosis?
- A. Client verbalizing symptoms of nausea
- B. 22-lb weight loss in 2 months
- C. Client verbalizes chills and fatigue
- D. Client seated and stating pain
Correct Answer: B
Rationale: The best objective data with useful information is the fact that the client has lost 22 pounds in 2 months, indicating significant weight loss in a short period of time. This is data that, with further questioning, could provide further details for diagnosis. A client verbalizing symptoms of nausea and pain constitutes subjective data. Viewing the client's seated posture offers little data.
When assisting with preparing a client scheduled for a barium swallow, which instruction would be appropriate to include?
- A. Avoid smoking for at least 12 to 24 hours before the procedure.
- B. Take vitamin K before the procedure.
- C. Take three cleansing enemas before the procedure.
- D. Avoid the intake of red meat before the procedure.
Correct Answer: A
Rationale: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
- A. A complete blood count including differential
- B. Serum antibodies for H. pylori
- C. A sigmoidoscopy
- D. Gastric analysis
Correct Answer: B
Rationale: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
The instructor has just finished teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders. The instructor determines that the teaching was successful when the students identify which structure as possibly being affected?
- A. Liver
- B. Ileum
- C. Stomach
- D. Large Intestine
Correct Answer: C
Rationale: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.
The nurse is examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract. Which would be the most important assessment for the nurse to make?
- A. Checking if the skin is discolored
- B. Checking if the mucous membranes are dry
- C. Examining the sclera if it is yellow
- D. Observing for distended abdominal veins
Correct Answer: B
Rationale: Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.