Nokea
Which outcome should the nurse identify for the client diagnosed with aphthous stomatitis?
- A. The client will be able to cope with perceived stress.
- B. The client will consume a balanced diet.
- C. The client will deny any difficulty swallowing.
- D. The client will take antacids as prescribed.
Correct Answer: C
Rationale: Aphthous stomatitis (canker sores) can cause painful swallowing, so denying difficulty swallowing is a key outcome. Stress coping and diet are secondary, and antacids are irrelevant.
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The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?
- A. Urine specific gravity value of 1.020
- B. High-pitched and tinkling bowel sounds
- C. Decreased lung sounds in both lung bases
- D. Client describes abdominal pain as colicky
Correct Answer: C
Rationale: Decreased lung sounds are the most concerning finding because it can be life-threatening. Massive distention can impair function of the diaphragm, which in turn leads to atelectasis and compromised respiratory function.
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 with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement?
- A. Maintain a strict record of intake and output.
- B. Insert a nasogastric (NG) tube and begin saline lavage.
- C. Assist the client with keeping a detailed calorie count.
- D. Provide a quiet environment to promote rest.
Correct Answer: B
Rationale: Inserting an NG tube with saline lavage helps remove blood, assess bleeding severity, and stabilize the client with frank gastric bleeding. Intake/output monitoring, calorie counts, and rest are secondary to controlling active hemorrhage.
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 clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer?
- A. Beginning at age 60, a digital rectal examination should be done yearly.
- B. After reaching middle age, a yearly fecal occult blood test should be done.
- C. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
- D. A flexible sigmoidoscopy should be done yearly after age 40.
Correct Answer: C
Rationale: The American Cancer Society recommends a colonoscopy starting at age 45–50, then every 5–10 years for average-risk individuals, as it effectively detects polyps and cancer. Other options are outdated or incorrect.