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Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?
- A. The client complains of clear to white sputum.
- B. The client has an episodic blister on the upper lip.
- C. The client complains of a nonhealing sore in the mouth.
- D. The client has bilateral ducts at the second molars.
Correct Answer: C
Rationale: A nonhealing sore in the mouth is concerning for oral cancer, a risk associated with oral tobacco use, requiring immediate assessment. Sputum, blisters, and salivary ducts are less significant.
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The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report?
- A. Abdominal cramping, nausea, and vomiting.
- B. Neuromuscular paralysis and dysphagia.
- C. Gross amounts of explosive bloody diarrhea.
- D. Frequent 'rice water stool' with no fecal odor.
Correct Answer: A
Rationale: Salmonellosis typically causes abdominal cramping, nausea, and vomiting due to bacterial irritation of the GI tract. Paralysis is botulism, bloody diarrhea is more typical of other pathogens, and rice water stool is cholera.
Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication?
- A. The client's pulse is 65 beats per minute.
- B. The client has shallow respirations.
- C. The client's bowel sounds are 20 per minute.
- D. The client uses a pillow to splint when coughing.
Correct Answer: B
Rationale: Shallow respirations suggest pain, as patients avoid deep breathing to minimize discomfort. Normal pulse, bowel sounds, and splinting are less direct indicators of pain.
The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement?
- A. Avoid rectal temperatures.
- B. Use only a soft toothbrush.
- C. Monitor the platelet count.
- D. Use small-gauge needles.
- E. Assess for asterixis.
Correct Answer: A,B,D
Rationale: Vitamin K deficiency impairs clotting, increasing bleeding risk, so avoiding rectal temperatures, using a soft toothbrush, and small-gauge needles minimize trauma. Platelet counts and asterixis are unrelated to bleeding risk.
The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals.
- B. Explain the need to decrease intake of flatus-forming foods.
- C. Teach the client how to perform gentle perianal care.
- D. Encourage the client to attend a support group meeting.
Correct Answer: B
Rationale: Decreasing flatus-forming foods (e.g., beans, broccoli) reduces bloating and discomfort in IBS. Avoiding fluids with meals is not standard, perianal care is secondary, and support groups are psychosocial.
Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications?
- A. Alteration in bowel elimination patterns.
- B. Knowledge deficit in the causes of ulcers.
- C. Inability to cope with changing family roles.
- D. Potential for alteration in gastric emptying.
Correct Answer: A
Rationale: Peptic ulcer disease can lead to complications like bleeding or perforation, which alter bowel elimination patterns (e.g., melena or hematochezia). Knowledge deficits and coping issues are psychosocial, and gastric emptying is less commonly affected.