Nokea
While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
- A. Bloody diarrhea
- B. Heartburn and regurgitation
- C. Abdominal distention
- D. Severe abdominal pain
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.
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A low-residue diet is ordered for a client. Which food would be contraindicated for this person?
- A. Roast beef
- B. Fresh peas
- C. Mashed potatoes
- D. Baked chicken
Correct Answer: B
Rationale: Fresh peas are high in residue due to their fiber content, contraindicated for a low-residue diet. Roast beef, mashed potatoes, and baked chicken are low-residue.
A nasogastric tube is ordered for an alert adult client. In addition to the tube and basin, what is essential for the nurse to have at the bedside during the procedure?
- A. A 5-cc syringe filled with water
- B. A glass filled with water and a straw
- C. A large clamp
- D. A container of sterile water
Correct Answer: B
Rationale: A glass of water with a straw helps the client swallow during nasogastric tube insertion, facilitating passage.
Which information should the nurse teach the client post-barium enema procedure?
- A. The client should not eat or drink anything for four (4) hours.
- B. The client should remain on bedrest until the sedative wears off.
- C. The client should take a mild laxative to help expel the barium.
- D. The client will have normal elimination color and pattern.
Correct Answer: C
Rationale: A mild laxative helps expel barium, preventing constipation or impaction post-barium enema. NPO, bedrest, and normal stool color are incorrect.
The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals.
- B. Explain the need to decrease intake of flatus-forming foods.
- C. Teach the client how to perform gentle perianal care.
- D. Encourage the client to attend a support group meeting.
Correct Answer: B
Rationale: Decreasing flatus-forming foods (e.g., beans, broccoli) reduces bloating and discomfort in IBS. Avoiding fluids with meals is not standard, perianal care is secondary, and support groups are psychosocial.
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.