Nokea
The nurse is conducting a community presentation on the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? Select all that apply.
- A. Fatigue.
- B. Unexplained weight loss with adequate nutritional intake.
- C. Rectal bleeding.
- D. Bowel changes.
- E. Positive fecal occult blood testing.
Correct Answer: A,B,C,D,E
Rationale: Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deficiency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer, and blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic. CN: Health promotion and maintenance; CL: Create
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The nurse evaluates the effectiveness of the client's postoperative plan of care. Which of the following would be an expected outcome for a client with an ileal conduit?
- A. The client verbalizes the understanding that his physical activity must be curtailed.
- B. The client states that he will place an aspirin in the drainage pouch to help control odor.
- C. The client demonstrates how to catheterize the stoma.
- D. The client states that he will empty the drainage pouch frequently throughout the day.
Correct Answer: D
Rationale: Frequent pouch emptying is an expected outcome, preventing complications like leakage or infection. Aspirin is unsafe, and stoma catheterization is not typical.
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses/treats bleeding, blood products (C) address hypovolemia, and Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention, not immediate.
The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease?
- A. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
- B. A 43-year-old male with a family history of CAD and cholesterol level of 158.
- C. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor).
- D. A 65-year-old female who is obese with an LDL of 188.
Correct Answer: D
Rationale: Obesity and elevated LDL (188) are significant risk factors for coronary artery disease. The other clients have lower-risk profiles due to younger age, smoking cessation, or controlled lipids.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition?
- A. Widening pulse pressure.
- B. Decrease in the pulse rate.
- C. Dilated, fixed pupils.
- D. Decrease in level of consciousness (LOC).
Correct Answer: A,B,C,D
Rationale: All listed changes are critical signs of increasing ICP. Widening pulse pressure (Cushing's triad), bradycardia, dilated fixed pupils, and decreased LOC indicate neurological deterioration requiring immediate notification of the health care provider for intervention.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.