Nokea
The nurse is completing the client’s hospital admission history. Which statement should prompt the nurse to further question the client about symptoms associated with GERD?
- A. “I have been experiencing headaches immediately after eating.”
- B. “Lately, I wake up at night with a burning feeling in my chest.”
- C. “I have been waking up at night sweating and wet all over.”
- D. “Immediately after eating I feel sleepy and want to go to bed.”
Correct Answer: B
Rationale: A. Headaches are a symptom not related to GERD. B. Heartburn, which is described as a burning, tight sensation in the lower sternum, is the most common symptom of GERD. It will often wake the client from sleep. C. Night sweats are a symptom not related to GERD. D. Postprandial sleepiness is a symptom not related to GERD.
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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.
Following a hemorrhoidectomy, the nurse is instructing the client in self-care. Which statement is especially important to include in these instructions?
- A. Wash the anal area with water after defecation and pat it dry.'
- B. Gently wipe the anal area after defecation from back to front.'
- C. Do not drink more than three glasses of fluid per day until after you have had the first bowel movement.'
- D. When you first feel the need to defecate, call me and I will give you the enema the doctor has ordered.'
Correct Answer: A
Rationale: Washing and patting dry promotes hygiene and healing post-hemorrhoidectomy, reducing irritation.
The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?
- A. Urine specific gravity value of 1.020
- B. High-pitched and tinkling bowel sounds
- C. Decreased lung sounds in both lung bases
- D. Client describes abdominal pain as colicky
Correct Answer: C
Rationale: Decreased lung sounds are the most concerning finding because it can be life-threatening. Massive distention can impair function of the diaphragm, which in turn leads to atelectasis and compromised respiratory function.
The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth. Which intervention should the nurse implement?
- A. Notify the health-care provider to obtain an antifungal medication.
- B. Explain the patches will go away naturally in about two (2) weeks.
- C. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily.
- D. Allow the client to verbalize feelings about having the plaques.
Correct Answer: A
Rationale: White, cheesy plaques suggest oral candidiasis, a common side effect of antibiotics. Notifying the HCP for an antifungal medication is the most appropriate intervention. The patches won’t resolve naturally, hydrogen peroxide is not standard, and verbalizing feelings is secondary.
Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery?
- A. Alteration in nutrition.
- B. Alteration in skin integrity.
- C. Alteration in urinary pattern.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Pain (alteration in comfort) is the highest priority post-cholecystectomy, as it affects recovery and mobility. Nutrition, skin, and urinary issues are secondary in the immediate postoperative period.