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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 teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis?
- A. Eat a high-fiber diet.
- B. Increase fluid intake.
- C. Elevate the HOB after eating.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: A,B,D
Rationale: High-fiber diet, increased fluids, and regular exercise (e.g., walking) prevent constipation and reduce pressure in diverticula, lowering exacerbation risk. Elevating the HOB and antacids are unrelated to diverticulosis prevention.
The day after surgery in which a colostomy was performed, the client says, 'I know the doctor did not really do a colostomy.' The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time?
- A. Agree with the client until the client is ready to accept the colostomy
- B. Say, 'It must be difficult to have this kind of surgery.'
- C. Force the client to look at his colostomy
- D. Ask the surgeon to explain the surgery to the client
Correct Answer: B
Rationale: Acknowledging the difficulty of the surgery supports the client emotionally during the denial stage without forcing confrontation.
The client is two (2) hours post colonoscopy. Which assessment data warrant immediate intervention by the nurse?
- A. The client has a soft, nontender abdomen.
- B. The client has a loose, watery stool.
- C. The client has hyperactive bowel sounds.
- D. The client's pulse is 104 and BP is 98/60.
Correct Answer: D
Rationale: Tachycardia (pulse 104) and low BP (98/60) suggest possible bleeding or hypovolemia post-colonoscopy, requiring immediate intervention. A soft abdomen, watery stool, and hyperactive bowel sounds are expected.
An adult has a nasogastric tube in place. Which nursing action will relieve discomfort in the nostril with the NG tube?
- A. Remove any tape and loosely pin the NG tube to his gown.
- B. Lubricate the NG tube with viscous lidocaine.
- C. Loop the NG tube to avoid pressure on the nares.
- D. Replace the NG tube with a smaller diameter tube.
Correct Answer: C
Rationale: Looping the NG tube reduces pressure on the nares, alleviating discomfort without compromising function.
The nurse is caring for a client diagnosed with bulimia nervosa. Which nursing intervention should the nurse implement after the client's evening meal?
- A. Praise the client for eating all the food on the tray.
- B. Stay with the client for 45 minutes to an hour.
- C. Allow the client to work out on the treadmill.
- D. Place the client on bedrest until morning.
Correct Answer: B
Rationale: Staying with the client prevents purging, a key behavior in bulimia, post-meal. Praising eating, exercise, or bedrest does not address purging.