Nokea
Which of the following factors would most likely contribute to the development of a client's hiatal hernia?
- A. Having a sedentary desk job.
- B. Being 5 feet, 3 inches tall and weighing 190 lb.
- C. Using laxatives frequently.
- D. Being 40 years old.
Correct Answer: B
Rationale: Obesity (e.g., 5'3†and 190 lb) increases intra-abdominal pressure, a major contributor to hiatal hernia development. The other factors are less directly related.
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The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders?
- A. Cholelithiasis.
- B. Hepatitis.
- C. Irritable bowel syndrome.
- D. Diabetes mellitus.
Correct Answer: D
Rationale: Chronic pancreatitis damages pancreatic tissue, impairing insulin production and increasing the risk of diabetes mellitus (D). Cholelithiasis (A), hepatitis (B), and irritable bowel syndrome (C) are less directly related.
A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate?
- A. It has been 4 days since your surgery and you will be discussed. You have to learn to care for your colostomy before you leave the hospital.
- B. I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it.
- C. I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness.
- D. I can see that you are upset. Would you like to share your concerns with me?
Correct Answer: D
Rationale: It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling. CN: Psychosocial adaptation; CL: Synthesize
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
Which symptom suggests a complication post-renal surgery?
- A. Urine output of 25 mL/hour.
- B. Temperature of 99°F.
- C. Mild incisional pain.
- D. Clear urine.
Correct Answer: A
Rationale: Low urine output (25 mL/hour) may indicate obstruction or renal impairment.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.