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When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:
- A. Controlling abdominal pain.
- B. Maintaining a regular bowel elimination pattern.
- C. Preventing respiratory complications.
- D. Maintaining a positive, optimistic outlook.
Correct Answer: D
Rationale: The correct answer is D: Maintaining a positive, optimistic outlook. This is because having a positive mindset can help the client cope better with the challenges of extended convalescence. It can improve overall well-being, mental health, and motivation for recovery.
A: Controlling abdominal pain - While abdominal pain may be a symptom of hepatitis A, it is not the most crucial aspect for extended convalescence.
B: Maintaining a regular bowel elimination pattern - While important for overall health, this is not specifically related to complications from hepatitis A.
C: Preventing respiratory complications - While respiratory complications can occur in severe cases of hepatitis A, it is not the most likely difficulty the client will face during extended convalescence.
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The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions most specifically would elicit information regarding the pain that is associated with acute pancreatitis?
- A. Does the pain in your abdomen radiate to your groin.
- B. Does the pain in your stomach radiate to the back?
- C. Does the pain in your stomach radiate to your lower middle abdomen?
- D. Does the pain in your lower abdomen radiate to the hip?
Correct Answer: B
Rationale: The correct answer is B: "Does the pain in your stomach radiate to the back?" This question is specific to acute pancreatitis as the pain typically radiates from the epigastric area to the back. Pancreatitis pain often presents as severe, constant, and radiating to the back due to the inflammation of the pancreas affecting surrounding structures.
Choice A is incorrect as the pain in acute pancreatitis typically radiates to the back, not the groin. Choice C is incorrect as it specifies a different area in the abdomen, not the typical location for pancreatitis pain. Choice D is incorrect as pancreatitis pain does not typically radiate to the hip.
In summary, understanding the characteristic radiation of pain in acute pancreatitis is key to assessing and differentiating it from other abdominal conditions.
A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?
- A. Place a sandbag over the insertion site.
- B. Allow the client bathroom privileges only.
- C. Encourage fluid intake.
- D. Allow the client to sit in a chair for meals.
Correct Answer: A
Rationale: The correct answer is A: Place a sandbag over the insertion site. This intervention helps maintain pressure on the puncture site, reducing the risk of bleeding or hematoma formation post-procedure. Placing a sandbag over the insertion site is a standard practice to ensure hemostasis and prevent complications.
Explanation for incorrect choices:
B: Allowing bathroom privileges only is unrelated to the specific care needs following a percutaneous transhepatic cholangiogram.
C: Encouraging fluid intake is a general nursing intervention and does not directly address the postprocedure care requirements for this specific procedure.
D: Allowing the client to sit in a chair for meals is not a priority post-procedure and does not address the potential complications associated with the puncture site.
A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming this diagnosis?
- A. Decreased erythrocyte sedimentation rate
- B. Elevated serum bilirubin
- C. Elevated hemoglobin
- D. Elevated blood urea nitrogen
Correct Answer: B
Rationale: The correct answer is B: Elevated serum bilirubin. Hepatitis is characterized by liver inflammation, which can lead to impaired bilirubin metabolism and increased levels in the blood. Elevated serum bilirubin is a common finding in hepatitis. Decreased erythrocyte sedimentation rate (Choice A) is not specific to hepatitis. Elevated hemoglobin (Choice C) and elevated blood urea nitrogen (Choice D) are not typically associated with hepatitis and are more indicative of other conditions. In summary, elevated serum bilirubin is a key diagnostic marker for confirming a diagnosis of hepatitis.
A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct Answer: B
Rationale: The correct answer is B: Oil-soluble lubricant. The rationale is that oil-based lubricants should not be used for nasogastric tube insertion due to the risk of aspiration pneumonia. The other options are appropriate for the procedure: A) Tape is used to secure the tube, C) Water with a straw is used to check tube placement, and D) A syringe is used for verification of tube placement and administration of medications. Therefore, selecting B indicates a lack of understanding of proper supplies for nasogastric tube insertion.
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructions?
- A. Lie down after meals to promote digestion.
- B. Avoid coffee and alcoholic beverages.
- C. Take antacids before meals.
- D. Limit fluids with meals.
Correct Answer: B
Rationale: The correct answer is B: Avoid coffee and alcoholic beverages. This is because both coffee and alcohol can relax the lower esophageal sphincter, leading to increased risk of gastroesophageal reflux in clients with hiatal hernia.
A: Lying down after meals can actually worsen reflux symptoms by allowing stomach acid to flow back into the esophagus.
C: Taking antacids before meals may provide temporary relief but does not address the underlying cause of reflux.
D: Limiting fluids with meals can help reduce reflux by not distending the stomach, but it is not as crucial as avoiding coffee and alcohol.