Which interventions should the nurse discuss regarding prevention of an acute exacerbation of diverticulosis? Select all that apply.
- A. Eat a low-fiber diet.
- B. Drink 2,500 mL of water daily.
- C. Avoid eating foods with seeds.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: B,C,D
Rationale: High fluid intake (2,500 mL), avoiding seeds, and exercise (walking) prevent constipation and reduce diverticulitis risk. Low-fiber diets worsen diverticulosis, and antacids are irrelevant.
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The 40-year-old client is recovering from an exacerbation of chronic pancreatitis. As the client prepares for discharge, the client makes several statements to the nurse. Which statement should be concerning because it could inhibit the client’s ability to accomplish the developmental tasks of middle adulthood?
- A. “I’m planning on continuing to be active in the local town service club.”
- B. “I enjoy my job; I should be able to return to work in about 3 to 4 weeks.”
- C. “I’ve missed friends and look forward to having a glass of wine with them.”
- D. “My spouse has been very supportive during my lengthy hospitalization.”
Correct Answer: C
Rationale: A. Volunteer activities meet the developmental task of middle adulthood of generativity. B. Planning to return to work meets the developmental task of middle adulthood of generativity. C. Consuming alcohol will cause continued progression of the pancreatic disease and could eventually result in the inability to work or to participate in community service. This statement should be concerning to the nurse. D. This statement indicates that the client has the support of another.
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.
A client had a barium enema. Following the barium enema, the nurse should anticipate an order for which of the following?
- A. An antacid
- B. A laxative
- C. A muscle relaxant
- D. A sedative
Correct Answer: B
Rationale: Barium is constipating, and a laxative is typically ordered to prevent bowel obstruction post-barium enema.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Assess the client for muscle weakness.
- C. Request telemetry for the client.
- D. Prepare to administer potassium IV.
Correct Answer: B
Rationale: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.
Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?
- A. How many years have you been drinking alcohol?
- B. Have you completed an advance directive?
- C. When did you have your last alcoholic drink?
- D. What foods did you eat at your last meal?
Correct Answer: C
Rationale: Recent alcohol consumption can exacerbate liver failure and affect treatment decisions, making it the priority question. Duration of drinking, advance directives, and diet are secondary.
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