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The nurse is completing a home visit with the client who had a partial resection of the ileum for Crohn’s disease 4 weeks previously. The nurse should collect additional information when the client makes which statement?
- A. “My stools float and seem to have fat in them.”
- B. “I have gained 5 pounds since I left the hospital.”
- C. “I am still avoiding milk and milk products.”
- D. “I am having only two formed stools per day.”
Correct Answer: A
Rationale: A. The nurse should collect additional information when the client states having stools that float and have fat in them. Bile salts are absorbed in the terminal ileum. Disease in this area or resection of the ileum can result in poor fat absorption and loss of fat in the stool. The presence of bile salts leads to diarrhea. B. Weight gain is a positive sign after small bowel resection for Crohn’s disease. C. Many clients with Crohn’s disease develop lactose intolerance and therefore should avoid milk products. D. Formed stools are a positive sign after small bowel resection for Crohn’s disease.
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Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa?
- A. Liver function tests.
- B. Kidney function tests.
- C. Cardiac function tests.
- D. Bone density scan.
Correct Answer: C
Rationale: Cardiac function tests (e.g., ECG) monitor for arrhythmias or heart failure, common in severe anorexia due to electrolyte imbalances and starvation. Liver, kidney, and bone tests are less urgent.
The nurse is assessing the client diagnosed with chronic gastritis. Which symptom(s) support this diagnosis?
- A. Rapid onset of midsternal discomfort.
- B. Epigastric pain relieved by eating food.
- C. Dyspepsia and hematemesis.
- D. Nausea and projectile vomiting.
Correct Answer: C
Rationale: Dyspepsia (indigestion) and hematemesis (vomiting blood) are symptoms of chronic gastritis due to mucosal irritation. Midsternal pain, pain relief with food, and projectile vomiting are less typical.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Assess the client for muscle weakness.
- C. Request telemetry for the client.
- D. Prepare to administer potassium IV.
Correct Answer: B
Rationale: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.
The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client?
- A. Explain the procedure will be done in the operating room.
- B. Instruct the client a Foley catheter will have to be inserted.
- C. Tell the client vital signs will be taken frequently after the procedure.
- D. Provide instructions on holding the breath when the HCP inserts the catheter.
Correct Answer: C
Rationale: Frequent vital sign monitoring post-paracentesis detects complications like hypotension or bleeding. Paracentesis is typically bedside, Foley catheters are unnecessary, and breath-holding is not standard.
Warm oatmeal (Aveeno) baths are ordered for a client with cancer of the pancreas. What is the chief purpose of this procedure for this client?
- A. Relief of paralytic ileus
- B. Alleviation of pruritus associated with jaundice
- C. Relief of bloating and fullness after eating
- D. Reducing the fever associated with the disease
Correct Answer: B
Rationale: Oatmeal baths alleviate pruritus caused by jaundice, a common symptom in pancreatic cancer due to bile salt accumulation.