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Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa?
- A. Liver function tests.
- B. Kidney function tests.
- C. Cardiac function tests.
- D. Bone density scan.
Correct Answer: C
Rationale: Cardiac function tests (e.g., ECG) monitor for arrhythmias or heart failure, common in severe anorexia due to electrolyte imbalances and starvation. Liver, kidney, and bone tests are less urgent.
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The nurse is caring for the client with diverticulitis. The nurse should plan to instruct the client to avoid which food during an episode of diverticulitis?
- A. White bread
- B. Ripe banana
- C. Cooked oatmeal
- D. Iceberg lettuce
Correct Answer: C
Rationale: A. White bread is a recommended food for fiber-restricted diets. It contains less than 1 g fiber per ounce. B. Ripe bananas, canned soft fruits, and most well-cooked vegetables without seeds or skins are recommended for fiber-restricted diets. C. Cooked oatmeal contains 4 g of fiber per serving. Foods high in fiber should be avoided during an episode of diverticulitis, and foods should be restricted to low fiber or clear liquids. Once diverticulitis is resolved, the client should return to a high-fiber diet. D. Iceberg lettuce contains less than 1 g of fiber.
The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. Which client problem should the nurse include in the intraoperative care plan?
- A. Fluid volume deficit.
- B. Impaired tissue perfusion.
- C. Infection of surgical site.
- D. Risk for immunosuppression.
Correct Answer: A
Rationale: Fluid volume deficit is a key intraoperative concern due to blood loss and fluid shifts during abdominal perineal resection. Perfusion, infection, and immunosuppression are postoperative risks.
The client had Billroth II surgery 24 hours ago. The client’s son approaches the nurse in the hallway and asks for information regarding his father’s condition. The wife is listed as the designated contact person. Which nurse response is best?
- A. “What has the surgeon told you about your father’s condition?”
- B. “Let’s both go into your father’s room and ask him how he feels.”
- C. “Let’s go to a more private place to discuss your father’s condition.”
- D. “Let’s review your father’s medical record information together.”
Correct Answer: B
Rationale: A. Discussing client information in a hospital hallway is inappropriate; individuals passing by could overhear confidential client information. B. Going into the client’s room together allows the client to determine if he wants to disclose information and how much information he wants to disclose. C. Even if in a private location, the nurse should not share confidential client information with anyone unless the client has specifically given permission. D. The nurse should not review the medical record of the client with a family member without permission. Some facilities require the client to complete a form requesting permission to review his or her own medical records.
The nurse is developing a plan of care for the client with cirrhosis. Which intervention should be included in the client’s plan of care?
- A. Monitor the client’s blood sugar level.
- B. Place the client on NPO status.
- C. Administer antibiotics every 6 hours.
- D. Encourage ambulation every 4 hours.
Correct Answer: A
Rationale: A. The nurse should prepare to monitor the client’s blood sugar level. The client with cirrhosis may develop insulin resistance. Impaired glucose tolerance is common with cirrhosis, and about 20% to 40% of clients also have diabetes. Hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. B. The client with cirrhosis would not be NPO but should receive a high-protein diet unless hepatic encephalopathy is present. C. Antibiotics are not part of the treatment plan of cirrhosis because it is not caused by microorganisms. D. The client with cirrhosis requires rest; thus, ambulation should not be encouraged every 4 hours.
While performing a home visit, the nurse observes that the client’s head of the bed is raised on 6-in. blocks. The nurse should question the client for a history of which conditions?
- A. Hiatal hernia
- B. Dumping syndrome
- C. Crohn’s disease
- D. Gastroesophageal reflux disease
- E. Gastritis
Correct Answer: A, D
Rationale: Clients with a hiatal hernia are encouraged to sleep with the HOB elevated on 4- to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. B. Dumping syndrome occurs after surgery when the stomach no longer has control over the amount of chime that enters the small intestine. Clients are encouraged to lie flat after a meal. C. Crohn’s disease is an inflammatory disease of the bowel. Positioning interventions do not decrease symptoms. D. Clients with GERD are encouraged to sleep with the HOB elevated on 4— to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. E. Gastritis is inflammation of the gastric mucosa. Positioning interventions do not decrease symptoms.