Nokea
The nurse is caring for a patient who has a diagnosis of AIDS. Inspection of the patient's mouth reveals the new presence of white lesions on the patient's oral mucosa. What is the nurse's most appropriate response?
- A. Encourage the patient to gargle with salt water twice daily.
- B. Attempt to remove the lesions with a tongue depressor.
- C. Make a referral to the unit's dietitian.
- D. Inform the primary care provider of this finding.
Correct Answer: D
Rationale: The nurse should inform the primary care provider of this abnormal finding in the patient's oral cavity, since it necessitates medical treatment. It would be inappropriate to try to remove skin lesions from a patient's mouth and salt water will not resolve this problem, which is likely due to candidiasis. A dietitian referral is unnecessary.
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A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation?
- A. Inflammatory bowel disease
- B. Intestinal polyps
- C. Diverticulitis
- D. Colon cancer
Correct Answer: A
Rationale: The use of a lavage solution is contraindicated in patients with intestinal obstruction or inflammatory bowel disease. It can safely be used with patients who have polyps, colon cancer, or diverticulitis.
A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?
- A. Increased gastric motility
- B. Decreased gastric pH
- C. Increased gag reflex
- D. Decreased mucus secretion
Correct Answer: D
Rationale: Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults.
A nurse is caring for an 83-year-old patient who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the patient's health complaint?
- A. Stomach emptying takes place more slowly.
- B. The villi and epithelium of the small intestine become thinner.
- C. The esophageal sphincter becomes incompetent.
- D. Saliva production decreases.
Correct Answer: A
Rationale: Delayed gastric emptying occurs in older adults and may contribute to nausea. Changes to the small intestine and decreased saliva production would be less likely to contribute to nausea. Loss of esophageal sphincter function is pathologic and is not considered an age-related change.
An inpatient has returned to the medical unit after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding should the nurse report to the physician?
- A. Large, wide stools
- B. Milky white stools
- C. Three stools during an 8-hour period of time
- D. Streaks of blood present in the stool
Correct Answer: D
Rationale: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.
A nursing student has auscultated a patient's abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds?
- A. Normal
- B. Hypoactive
- C. Hyperactive
- D. Paralytic ileus
Correct Answer: B
Rationale: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.