Nokea
Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis?
- A. Twenty bloody stools a day.
- B. Oral temperature of 102°F.
- C. Hard, rigid abdomen.
- D. Urinary stress incontinence.
Correct Answer: A
Rationale: Ulcerative colitis commonly causes frequent bloody stools due to inflammation and ulceration of the colon mucosa. Fever may occur but is less specific, a hard abdomen suggests complications like perforation, and urinary incontinence is unrelated.
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Which problem is most appropriate for the nurse to identify for the client with diarrhea?
- A. Alteration in skin integrity.
- B. Chronic pain perception.
- C. Fluid volume excess.
- D. Ineffective coping.
Correct Answer: A
Rationale: Diarrhea can cause perianal skin breakdown, making alteration in skin integrity the most appropriate problem. Pain is less common, fluid volume is deficient, and coping is secondary.
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 client is admitted to a medical unit. The client’s medication list includes rifaximin, lactulose, and propranolol. Which assessment should be the nurse’s priority based on the client’s medication list?
- A. Assess the client for a history of PUD.
- B. Assess the client for abdominal pain.
- C. Place the client on airborne precautions.
- D. Assess neurological status and abdominal girth.
Correct Answer: D
Rationale: A. Antibiotics and acid-reducing medications are expected with the treatment of PUD, but propranolol (Inderal) would not be expected. Although these medications may cue the nurse to further explore a history of PUD, this is not the most likely conclusion. B. There is no indication that the client has abdominal pain, and there isn’t an analgesic on the medication list. C. There is no indication that the client has an infectious condition necessitating airborne precautions. D. All medications listed are used to treat liver cirrhosis and its complications of portal hypertension and hepatic encephalopathy. The antibiotic rifaximin (Xifaxan) and the laxative lactulose (Cephulac) are used for treating hepatic encephalopathy. Thus, assessing the client’s neurological status and measuring abdominal girth are most important.
The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching?
- A. Grilled hamburger on a wheat bun and fried potatoes.
- B. A chicken salad sandwich and lettuce and tomato salad.
- C. Roast pork, white rice, and plain custard.
- D. Fried fish, whole grain pasta, and fruit salad.
Correct Answer: C
Rationale: A low-residue diet minimizes fiber to reduce bowel irritation, so roast pork, white rice, and plain custard (low-fiber foods) are appropriate. The other options include high-fiber foods like wheat, vegetables, and whole grains, which are contraindicated.
Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?
- A. The client complains of clear to white sputum.
- B. The client has an episodic blister on the upper lip.
- C. The client complains of a nonhealing sore in the mouth.
- D. The client has bilateral ducts at the second molars.
Correct Answer: C
Rationale: A nonhealing sore in the mouth is concerning for oral cancer, a risk associated with oral tobacco use, requiring immediate assessment. Sputum, blisters, and salivary ducts are less significant.