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The nurse is caring for the client with acute diverticulitis. Which finding should most prompt the nurse to consider that the client has developed an intestinal perforation?
- A. White blood cells (WBCs) elevated
- B. Temperature of 101°F (38.3°C)
- C. Bowel sounds are absent
- D. Reports intense abdominal pain
Correct Answer: C
Rationale: A. Elevated WBCs are a symptom of acute diverticulitis. B. Increased temperature is a symptom of acute diverticulitis. C. Clients with intestinal perforation develop paralytic ileus. Bowel sounds would be absent. D. Abdominal pain is a symptom of acute diverticulitis that may worsen with intestinal perforation, but the most significant finding would be absent bowel sounds.
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The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication every day and prn.
- B. Perform bowel training every two (2) hours.
- C. Administer an oil retention enema.
- D. Prepare for an upper gastrointestinal (UGI) series x-ray.
Correct Answer: C
Rationale: An oil retention enema softens and facilitates removal of impacted stool. Antidiarrheals are contraindicated, bowel training is long-term, and UGI is irrelevant.
The nurse is preparing a client with Crohn's disease for discharge. Which of the following statements indicates that he needs further teaching?
- A. Stress can make it worse.'
- B. Since I have Crohn's disease, I don't have to worry about colon cancer.'
- C. I realize I shall always have to monitor my diet.'
- D. I understand there is a high incidence of familial occurrence with this disease.'
Correct Answer: B
Rationale: Crohn’s disease increases the risk of colon cancer, so the statement indicates a need for further teaching. The other statements are correct.
The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.
The weight loss clinic nurse identifies the concept of nutrition for a client diagnosed with obesity. Which interventions should the nurse implement? Select all that apply.
- A. Ask the client about previous diet attempts.
- B. Refer the client to the dietitian.
- C. Discuss maintaining a sedentary lifestyle.
- D. Weigh the client.
- E. Assist the client to set a realistic weight loss goal.
Correct Answer: A,B,D,E
Rationale: Asking about diets, dietitian referral, weighing, and setting goals support nutritional management for obesity. A sedentary lifestyle is contraindicated.
The nurse is caring for a client diagnosed with ulcerative colitis. Which symptom(s) support this diagnosis?
- A. Increased appetite and thirst.
- B. Elevated hemoglobin.
- C. Multiple bloody, liquid stools.
- D. Exacerbations unrelated to stress.
Correct Answer: C
Rationale: Multiple bloody, liquid stools are a hallmark of ulcerative colitis due to mucosal inflammation. Appetite/thirst increase, elevated hemoglobin, and stress-unrelated exacerbations are incorrect.