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While performing a home visit, the nurse observes that the client’s head of the bed is raised on 6-in. blocks. The nurse should question the client for a history of which conditions?
- A. Hiatal hernia
- B. Dumping syndrome
- C. Crohn’s disease
- D. Gastroesophageal reflux disease
- E. Gastritis
Correct Answer: A, D
Rationale: Clients with a hiatal hernia are encouraged to sleep with the HOB elevated on 4- to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. B. Dumping syndrome occurs after surgery when the stomach no longer has control over the amount of chime that enters the small intestine. Clients are encouraged to lie flat after a meal. C. Crohn’s disease is an inflammatory disease of the bowel. Positioning interventions do not decrease symptoms. D. Clients with GERD are encouraged to sleep with the HOB elevated on 4— to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. E. Gastritis is inflammation of the gastric mucosa. Positioning interventions do not decrease symptoms.
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The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person?
- A. Hepatitis A.
- B. Hepatitis B.
- C. Hepatitis C.
- D. Hepatitis D.
Correct Answer: A
Rationale: Hepatitis A is transmitted via the fecal-oral route through contaminated food, water, or contact, common in settings like daycares. Other types are bloodborne or require co-infection.
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Draw the serum liver function test.
- B. Evaluate the client’s intake and output.
- C. Perform the bedside glucometer check.
- D. Help the ward clerk transcribe orders.
Correct Answer: C
Rationale: Performing a glucometer check is within the UAP’s scope with proper training. Drawing blood, evaluating intake/output, and transcribing orders require RN skills.
The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis?
- A. Esophagogastroduodenoscopy.
- B. Magnetic resonance imaging (MRI).
- C. Occult blood test.
- D. Gastric acid stimulation.
Correct Answer: A
Rationale: Esophagogastroduodenoscopy (EGD) directly visualizes the gastric mucosa to confirm the presence of ulcers, making it the gold standard for diagnosing peptic ulcer disease. MRI is not used, occult blood tests are nonspecific, and gastric acid stimulation assesses acid production, not ulcers.
Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery?
- A. Alteration in nutrition.
- B. Alteration in skin integrity.
- C. Alteration in urinary pattern.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Pain (alteration in comfort) is the highest priority post-cholecystectomy, as it affects recovery and mobility. Nutrition, skin, and urinary issues are secondary in the immediate postoperative period.
The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5'10 tall and weighs 45 kg. Which assessment data should the nurse obtain first?
- A. Ask the client to recall what she ate for the last 24 hours.
- B. Determine what type of birth control the client has been using.
- C. Reweigh the client to confirm the data.
- D. Take the client's pulse and blood pressure.
Correct Answer: D
Rationale: Low weight (BMI ~13.6) suggests anorexia, and vital signs (pulse, BP) assess for hemodynamic instability, a priority. Diet recall, birth control, and reweighing are secondary.