Nokea
The nurse is obtaining a history for a female patient who is being evaluated for acute lower abdominal pain and vomiting. Which of the following questions is most useful in determining the cause of the patient's symptoms?
- A. Is it possible that you are pregnant?
- B. Can you tell me more about the pain?
- C. What type of foods do you usually eat?
- D. What is your usual elimination pattern?
Correct Answer: B
Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain.
You may also like to solve these questions
Which of the following nursing actions should be included in the plan of care for a male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)?
- A. Encourage the patient to express feelings and ask questions about IBS.
- B. Suggest that the patient increase the intake of milk and other dairy products.
- C. Educate the patient about the use of metronidazole to reduce symptoms.
- D. Teach the patient to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs).
Correct Answer: A
Rationale: Because psychological and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Metronidazole is an antimicrobial used for infections, not IBS, at the present time. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.
A patient tells the nurse, 'I have problems with constipation now that I am older, so I use a suppository every morning.' Which of the following actions should the nurse take first?
- A. Encourage the patient to increase oral fluid intake
- B. Inform the patient that a daily bowel movement is unnecessary.
- C. Assess the patient about individual risk factors for constipation.
- D. Suggest that the patient increase dietary intake of high-fibre foods.
Correct Answer: C
Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment.
The nurse is caring for a patient who has a large bowel obstruction that occurred as a result of diverticulosis. Which of the following symptoms should the nurse monitor for when assessing the patient?
- A. Referred back pain
- B. Metabolic alkalosis
- C. Projectile vomiting
- D. Abdominal distension
Correct Answer: D
Rationale: Abdominal distension is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-coloured vomit is associated with higher intestinal obstruction.
Which of the following actions should the nurse implement when initiating the initial plan of care for a patient admitted with acute diverticulitis?
- A. Give stool softeners.
- B. Administer IV fluids.
- C. Order a diet high in fibre and fluids.
- D. Prepare the patient for colonoscopy.
Correct Answer: B
Rationale: A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fibre and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool
During the initial postoperative assessment of a patient's stoma formed from a transverse colostomy, the stoma appearance indicates good circulation to the stoma. Which of the following actions should the nurse take based upon these findings?
- A. Document the stoma assessment
- B. Assess the stoma every 30 minutes
- C. Notify the surgeon about the stoma
- D. Place an ice pack on the stoma to reduce swelling
Correct Answer: A
Rationale: The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2-3 weeks after surgery, and an ice pack is not needed.