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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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A client with cirrhosis is about to have a paracentesis for relief of ascites. Which activity is essential prior to the procedure?
- A. Administer thorough mouth care.
- B. Ask the client to empty his bladder.
- C. Be sure his bowels have moved recently.
- D. Have the client bathe with betadine.
Correct Answer: B
Rationale: Emptying the bladder prevents accidental puncture during paracentesis, which involves inserting a needle into the abdominal cavity.
The nurse writes the problem 'risk for impaired skin integrity' for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?
- A. The client will have intact skin around the stoma.
- B. The client will be able to change the ostomy bag.
- C. The client will express anxiety about the body changes.
- D. The client will maintain fluid balance.
Correct Answer: A
Rationale: Intact skin around the stoma directly addresses the risk for impaired skin integrity due to colostomy leakage or irritation. Other outcomes are unrelated or secondary.
Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?
- A. How many years have you been drinking alcohol?
- B. Have you completed an advance directive?
- C. When did you have your last alcoholic drink?
- D. What foods did you eat at your last meal?
Correct Answer: C
Rationale: Recent alcohol consumption can exacerbate liver failure and affect treatment decisions, making it the priority question. Duration of drinking, advance directives, and diet are secondary.
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.
The client with hepatitis asks the nurse, 'I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?' Which statement is the nurse's best response?
- A. You are concerned about taking an herb.
- B. The herb has been used to treat liver disease.
- C. I would not take anything that is not prescribed.
- D. Why would you want to take any herbs?
Correct Answer: B
Rationale: Milk thistle is commonly used for liver support and may have hepatoprotective effects, though evidence is limited. This response provides accurate information without dismissing the client’s query.