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What should the nurse admitting a patient with acute diverticulitis plan for initial care?
- A. Administer IV fluids.
- B. Prepare for colonoscopy.
- C. Encourage a high-fiber diet.
- D. Give stool softeners and enemas.
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. Initial care for acute diverticulitis involves IV fluids to maintain hydration and electrolyte balance, as patients often have nausea, vomiting, and decreased oral intake. IV fluids help prevent dehydration and support the body during the acute phase of the condition. Options B, C, and D are incorrect. Colonoscopy is contraindicated during acute diverticulitis due to the risk of perforation. High-fiber diet and stool softeners/enemas are not recommended initially as they can worsen symptoms and increase the risk of complications.
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A client is admitted to the hospital for a hemorrhoidectomy. Postoperatively, which of the following would a client's nurse be most concerned about?
- A. Pain at the incision site
- B. White blood count of 6.5
- C. Client's refusal of a stool softener
- D. Excessive bloody drainage on the external gauze dressing
Correct Answer: D
Rationale: The correct answer is D because excessive bloody drainage on the external gauze dressing could indicate hemorrhage, a serious complication post-hemorrhoidectomy. This requires immediate medical attention to prevent further complications.
A: Pain at the incision site is expected postoperatively and can be managed with pain medication.
B: A white blood count of 6.5 is within the normal range and not a cause for concern.
C: Client's refusal of a stool softener is important for bowel movement management but is not the most immediate concern compared to excessive bloody drainage.
A nurse is providing discharge teaching to a client who has gastroesophageal reflux disease. Which of the following statements by the client indicates an understanding of the teaching?
- A. The type of foods I eat does not affect this condition.'
- B. I will sleep on my left side.'
- C. I will eat a snack just before going to bed.'
- D. I will sleep with the head of my bed elevated.'
Correct Answer: D
Rationale: The correct answer is D. Elevating the head of the bed helps prevent acid reflux by keeping the stomach acid from flowing back into the esophagus while sleeping. This position helps gravity keep the acid in the stomach. Choice A is incorrect because certain foods can indeed trigger or worsen GERD symptoms. Choice B is incorrect as sleeping on the left side may worsen symptoms due to the position of the stomach. Choice C is incorrect as eating right before bed can increase the risk of acid reflux.
What test will be done before prescribing treatment for the patient with positive testing for HCV?
- A. Anti-HCV
- B. HCV RNA quantitation
- C. HCV genotyping
- D. Recombinant immunoblot assay (RIBA)
Correct Answer: C
Rationale: The correct answer is C: HCV genotyping. Before prescribing treatment for a patient with positive HCV testing, genotyping is essential to determine the specific strain of HCV present. This information guides treatment decisions as different HCV genotypes respond differently to antiviral medications. Anti-HCV (choice A) is used for initial screening but does not provide genotype information. HCV RNA quantitation (choice B) measures viral load but does not identify the genotype. Recombinant immunoblot assay (RIBA) (choice D) is an older confirmatory test and is not typically used for initial treatment decision-making.
A male patient who has undergone an anterior-posterior repair is worried about his sexuality. What is an appropriate nursing intervention for this patient?
- A. Have the patient's sexual partner reassure the patient that he is still desirable.
- B. Reassure the patient that sexual function will return when healing is complete.
- C. Remind the patient that affection can be expressed in ways other than through sexual intercourse.
- D. Explain that physical and emotional factors can affect sexual function but not necessarily the patient's sexuality.
Correct Answer: C
Rationale: Rationale:
1. Choice C is correct because it acknowledges the patient's concerns about sexuality post-surgery.
2. Reminding the patient that affection can be expressed in non-sexual ways validates his feelings.
3. It promotes open communication and offers alternative ways to maintain intimacy during the healing process.
Summary of Incorrect Choices:
A. Involving the sexual partner may add pressure and may not address the patient's personal insecurities.
B. Promising a return to normal sexual function may create false expectations and overlook emotional aspects.
D. Focusing on physical and emotional factors may downplay the patient's specific concerns about his sexuality.
Which structure is located where the esophagus penetrates the diaphragm?
- A. esophageal hiatus
- B. cardiac orifice
- C. upper esophageal sphincter
- D. lower esophageal sphincter
Correct Answer: A
Rationale: The correct answer is A: esophageal hiatus. This is the opening in the diaphragm through which the esophagus passes, connecting the thoracic and abdominal cavities. The esophageal hiatus is specifically located at the level of the tenth thoracic vertebra. The other choices are incorrect because:
B: Cardiac orifice refers to the opening of the stomach into the esophagus, not where the esophagus penetrates the diaphragm.
C: Upper esophageal sphincter is a muscular valve at the upper end of the esophagus, not related to its passage through the diaphragm.
D: Lower esophageal sphincter is located at the junction of the esophagus and stomach, not at the point where the esophagus penetrates the diaphragm.