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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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The client with liver problems asks the nurse, 'Why are my stools clay-colored?' On which scientific rationale should the nurse base the response?
- A. There is an increase in serum ammonia level.
- B. The liver is unable to excrete bilirubin.
- C. The liver is unable to metabolize fatty foods.
- D. A damaged liver cannot detoxify vitamins.
Correct Answer: B
Rationale: Clay-colored stools result from the liver’s inability to excrete bilirubin, which gives stool its brown color. Ammonia, fat metabolism, and vitamin detoxification are unrelated.
The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately?
- A. A serum sodium of 128 mEq/L in a client diagnosed with obstipation.
- B. The client diagnosed with fecal impaction who had two (2) hard formed stools.
- C. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea.
- D. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.
Correct Answer: A
Rationale: Hyponatremia (sodium 128 mEq/L) in obstipation risks neurological complications, requiring immediate HCP attention. Formed stools, normal potassium, and moderate diarrhea are less urgent.
The nurse is teaching the American Diabetes Association diet to a client diagnosed with diabetes mellitus type 2. Which should the nurse teach the client?
- A. Instruct the client to weigh all food before cooking it.
- B. Teach the client to eat only carbohydrates if the blood glucose is low.
- C. Demonstrate how to determine the amount of carbohydrates being eaten.
- D. Explain that proteins should be 75% of the recommended diet.
Correct Answer: C
Rationale: Determining carbohydrate amounts (e.g., carb counting) is key for glycemic control in type 2 diabetes per ADA guidelines. Weighing food, carb-only for hypoglycemia, and high protein are incorrect.
The client asks how he contracted hepatitis A. He reports all of the following. Which one is most likely related to hepatitis A?
- A. He ate home-canned corn.
- B. He ate oysters his roommate brought home from a fishing trip.
- C. He stepped on a nail two weeks ago.
- D. He donated blood two weeks before he got sick.
Correct Answer: B
Rationale: Hepatitis A is transmitted via the fecal-oral route, often through contaminated food like oysters. Oysters from unsafe waters are a common source.
Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy?
- A. Clay-colored stools.
- B. Yellow-tinted sclera.
- C. Amber-colored urine.
- D. WGold-colored urine.
- E. Wound approximated.
- F. Abdominal pain.
Correct Answer: A,B,E
Rationale: Clay-colored stools and yellow-tinted sclera indicate possible bile duct obstruction or jaundice, while abdominal pain suggests complications like infection or bile leak, all requiring HCP notification. Amber urine and approximated wounds are less urgent.