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Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C?
- A. Decrease alcohol intake.
- B. Encourage rest periods.
- C. Eat a large evening meal.
- D. Drink diet drinks and juices.
Correct Answer: B
Rationale: Rest periods conserve energy and support recovery during the icteric phase of hepatitis C, when jaundice and fatigue are prominent. Alcohol avoidance is general advice, and diet changes are less specific.
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While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
- A. Bloody diarrhea
- B. Heartburn and regurgitation
- C. Abdominal distention
- D. Severe abdominal pain
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.
A child with appendicitis is scheduled for surgery this evening. The nurse enters the room and sees the child's mother starting to place hot, wet washcloths on her daughter's abdomen so that 'she will feel better.' The nurse explains that this action is contraindicated because heat:
- A. can cause the appendix to rupture and cause peritonitis.
- B. can mask symptoms of acute appendicitis.
- C. will increase peristalsis throughout the abdomen.
- D. will arrest progression of the disease.
Correct Answer: A
Rationale: Heat can increase inflammation and blood flow, risking appendix rupture and peritonitis in appendicitis.
The client has had a liver biopsy. Which postprocedure intervention should the nurse implement?
- A. Instruct the client to void immediately.
- B. Keep the client NPO for eight (8) hours.
- C. Place the client on the right side.
- D. Monitor blood urea nitrogen (BUN) and creatinine level.
Correct Answer: C
Rationale: Placing the client on the right side applies pressure to the biopsy site, reducing bleeding risk. Voiding, NPO status, and BUN/creatinine are not specific to liver biopsy care.
The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6°F. Which intervention should the nurse implement first?
- A. Notify the health-care provider.
- B. Document the findings in the chart.
- C. Administer an oral antipyretic.
- D. Assess the client's abdomen.
Correct Answer: D
Rationale: Assessing the abdomen first provides critical data on tenderness, rigidity, or rebound, which could indicate complications like perforation, guiding further actions. Notification or medication follows assessment.
The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge instructions?
- A. I should not eat for at least one (1) day following this procedure.
- B. I can lie down whenever I want after a meal. It won't make a difference.
- C. The stomach contents won't bother my esophagus but will make me nauseous.
- D. I should avoid orange juice and eating tomatoes until my esophagus heals.
Correct Answer: D
Rationale: Avoiding acidic foods like orange juice and tomatoes reduces irritation to the esophagus, indicating understanding of dietary modifications for GERD. Not eating for a day is unnecessary, lying down after meals worsens reflux, and nausea is not the primary concern with GERD.