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The nurse is reviewing the history and physical of a teenager admitted to a hospital with a diagnosis of ulcerative colitis. Based on this diagnosis, which information should the nurse expect to see on this client’s medical record?
- A. Heartburn and regurgitation
- B. Abdominal pain and bloody diarrhea
- C. Weight gain and elevated blood glucose
- D. Abdominal distention and hypoactive bowel sounds
Correct Answer: B
Rationale: A. Heartburn and regurgitation are not symptoms of ulcerative colitis. B. The nurse should expect to read about the primary symptoms of ulcerative colitis, which are bloody diarrhea and abdominal pain. C. Weight loss, not weight gain, often occurs in severe cases of ulcerative colitis. D. Bowel sounds are often hyperactive rather than hypoactive in ulcerative colitis.
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The nurse is preparing to care for the client immediately after a Whipple procedure. The nurse should plan to include which action?
- A. Monitor the blood glucose levels
- B. Administer enteral feedings
- C. Irrigate the NG tube with 30 mL of saline
- D. Assist with bowel elimination within 8 hours of surgery
Correct Answer: A
Rationale: A. The Whipple procedure induces insulin-dependent diabetes because the proximal pancreas is resected. Thus, the blood glucose levels should be monitored closely starting immediately after surgery. B. Parenteral (not enteral) feedings are the method of choice for providing nutrition immediately after surgery. C. The NG tube is strategically placed during surgery and should not be irrigated without a surgeon’s order. With an order, gentle irrigation with 10 to 20 mL of NS is appropriate. D. Since this surgery reshapes the GI tract, the client will not have peristalsis and bowel movements for several days.
Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease?
- A. Auscultate the client's bowel sounds in all four quadrants.
- B. Palpate the abdominal area for tenderness.
- C. Percuss the abdominal borders to identify organs.
- D. Assess the tender area progressing to nontender.
Correct Answer: B
Rationale: Palpating for tenderness helps identify epigastric pain, a key symptom of peptic ulcer disease, and guides further assessment. Auscultation, percussion, and specific tender-to-nontender assessment are secondary in this context.
The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.
The nurse is caring for the client with acute diverticulitis. Which finding should most prompt the nurse to consider that the client has developed an intestinal perforation?
- A. White blood cells (WBCs) elevated
- B. Temperature of 101°F (38.3°C)
- C. Bowel sounds are absent
- D. Reports intense abdominal pain
Correct Answer: C
Rationale: A. Elevated WBCs are a symptom of acute diverticulitis. B. Increased temperature is a symptom of acute diverticulitis. C. Clients with intestinal perforation develop paralytic ileus. Bowel sounds would be absent. D. Abdominal pain is a symptom of acute diverticulitis that may worsen with intestinal perforation, but the most significant finding would be absent bowel sounds.
Which disease is the client diagnosed with GERD at greater risk for developing?
- A. Hiatal hernia.
- B. Gastroenteritis.
- C. Esophageal cancer.
- D. Gastric cancer.
Correct Answer: C
Rationale: Chronic GERD increases the risk of esophageal cancer, particularly adenocarcinoma, due to prolonged acid exposure causing Barrett's esophagus, a precancerous condition. Hiatal hernia is a risk factor for GERD, not a consequence, and gastroenteritis and gastric cancer are less directly linked.