Question 1

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement?

Accepted Answer

The client may not be an appropriate transplant candidate due to his alcohol use. However, additional facts are needed to determine the true situation as the only information obtained came from the client's spouse. The nurse should assess the client's drinking habits and motivation to stop drinking before and after the transplant by speaking with the client directly. In addition, a transplant requires many other self-care regimens. The nurse should be alert for indicators of the client's ability to take prescribed medications, follow dietary restrictions, and attend medical appointments. The information obtained from this assessment should be communicated to the interdisciplinary team members responsible for determining transplant eligibility. (Option A) Transplant and hospice care are options for the client with end-stage liver disease; palliative specialists can assist with identifying the goals of care and facilitating decision-making. However, this does not directly address the concern of the client's spouse. At this time, further assessment is necessary before appropriate interventions can be planned. (Option C) At this point, it is unclear whether the client is motivated to quit drinking (the nurse has only heard from the spouse). Therefore, it is premature to plan for this type of intervention. The client will need to stay sober not just prior to the surgery, but for a lifetime if the transplant occurs. Any discussion between the client's family and the medical team should be based on this understanding. (Option D) If the nurse is concerned about transplant eligibility due to the spouse's statement, then this should be communicated to the client's interdisciplinary team after further assessment. At this point, it is premature to involve the nurse manager. Educational objective: The client with end-stage organ failure must be motivated and able to engage in complex self-care regimens before and after solid organ transplant. Concerns about the client's motivation to engage in necessary self-care requirements (eg, alcohol abstinence) require further assessment.

Question 2

The nurse is admitting a client with cholelithiasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority?

Accepted Answer

11ecbb05_c990_e797_b433_23279c80ecdb_MD0009_00 The highest priority intervention for an actively vomiting client with cholelithiasis is maintenance of strict NPO status to avoid additional gallbladder stimulation. Additional collaborative interventions (see table) for cholecystitis should also be taken into account. (Option A) Promethazine 25 mg suppository is the second priority. Promethazine promotes the relief of nausea and vomiting and minimizes further fluid loss. (Option B) Obtaining fluid and electrolyte replacement with sodium chloride 100 mL/hr is the third priority and assists in the maintenance of fluid balance. (Option C) Insertion of a nasogastric (NG) tube to low suction is the fourth priority. NG suction provides gastric decompression, alleviates nausea and vomiting, and promotes bowel rest. Educational objective: The highest priority intervention for an actively vomiting client with acute cholecystitis is maintenance of strict NPO status to avoid additional stimulation of the gallbladder. Additional priorities include management of nausea and vomiting, pain, fluid balance, and gastric decompression.

Question 3

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission. Which foods would be the best for this client?

Accepted Answer

Reduced appetite and significant, unintentional weight loss are included in the diagnostic criteria for unipolar major depression (major depressive disorder). A 35-lb (15.9-kg) weight loss within 3 months is a 23% change in this client's usual body weight and is considered severe weight loss. The client needs a diet high in calories and protein to promote adequate nutrition and weight gain. In addition, the client has a diagnosis of depression and may have a low energy level; providing foods that are easier to chew and swallow may be better choices for promoting intake. Foods that are protein and/or calorie dense include: Whole milk and dairy products (eg, milkshakes), fruit smoothies Granola, muffins, biscuits Potatoes with sour cream and butter Meat, fish, eggs, dried beans, almond butter Pasta/rice dishes with cream sauce (Option A) The client is taking phenelzine (Nardil), which is a monoamine oxidase inhibitor (MAOI). Foods high in tyramine (eg, aged cheese, yogurt, cured meats, fermented foods, broad beans, beer, red wine, chocolate, avocados) need to be restricted to reduce the risk of a hypertensive crisis. (Option B) This choice is an excellent protein option but is low in calories. The client needs foods high in calories and protein. (Option D) This choice provides calories but is low in protein and high in tyramine. The client needs to consume foods that are high in calories and protein but low in tyramine. Educational objective: Clients with unipolar major depression are likely to have reduced appetite and unintentional weight loss. Interventions to promote adequate nutritional intake include providing small frequent meals and snacks that are dense in protein and calories. In addition, drug-nutrient interactions need to be considered when choosing foods for a client on an MAOI.

Question 4

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?

Accepted Answer

Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness). The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately. (Option B) Clients with acute diverticulitis can bleed. Usually this bleeding is quite obvious, often with a large amount of bright red blood seen in the stool. This client's mild anemia is nonspecific and should not be given reporting priority over the peritoneal signs. (Option C) This indicates fetal position and could be due to pain. Clients with peritonitis are expected to lie still as any movement worsens the pain. Peritonitis takes priority over the expected pain in diverticulitis. (Option D) Leukocytosis is expected with acute diverticulitis. However this client's white blood cell count is only minimally elevated (upper limit of normal is 11,000/mm³ [11.0 x 10⁹/L]) and is not a priority over possible peritoneal signs. Educational objective: Diverticulitis is caused by inflammation of diverticula (outpouchings) of the large intestine that can lead to abscess, perforation, peritonitis, and/or bleeding. Peritonitis is a potentially fatal complication that should be reported to the health care provider immediately.

Question 5

A client is admitted with severe acute pancreatitis.  While obtaining the client's blood pressure, the nurse notices a carpal spasm.  What laboratory result would the nurse assess in response to this symptom?

Accepted Answer

11ecbb05_c99b_95fe_b433_cda8d69d5369_MD0009_00 Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia (capillary leak → third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to hypocalcemia. (Option A) Decreased albumin levels are seen with malnutrition; clients who are alcoholics can have low serum albumin but that alone is not responsible for the client's symptom. (Option B) Troponin elevation is specific to myocardial infarction and is unrelated to pancreatitis. (Option C) Potassium abnormalities are not usually present in acute pancreatitis. They are more likely to occur with hemolysis, when the intracellular potassium enters the serum. The ecchymoses in pancreatitis (Grey Turner's sign, Cullen's sign) are due to the blood-stained exudates from autodigestion and are usually only seen in severe cases. Educational objective: Complications of acute severe pancreatitis include hyperglycemia, hypocalcemia, hypovolemia, and ARDS. Trousseau's (carpal spasm) and Chvostek's (facial twitching) signs are an indication of hypocalcemia from the decrease in threshold for contraction.

Question 6

An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment?

Accepted Answer

Malnutrition occurs due to inadequate intake of major nutrients (eg, calories, carbohydrates, fat, protein) or micronutrients (eg, minerals, vitamins). As malnutrition worsens and protein intake is reduced, muscles become fatigued and weak. Clinical manifestations depend on the severity of the malnutrition, ranging from mild to extreme (eg, emaciation). Weight gain is the best indicator that the client is responding to medical nutritional therapy. (Option A) Consuming 90% of meals indicates that the client's appetite is good or improving but does not provide conclusive evidence of an improved nutritional status. (Option B) Although a serum albumin level of 3.6 g/dL (36 g/L) is within the normal range of 3.5-5.0 g/dL (35-50 g/L), visceral protein stores are poor indicators of nutritional status in acute and chronic disease. During an inflammatory response (eg, pneumonia), protein synthesis by the liver is decreased. Serum albumin has a long half-life, so laboratory levels may not reflect the change in nutritional status for over 2 weeks. Prealbumin has a half-life of only 2 days and is quicker and more reliable than serum albumin as an indicator of acute change in nutritional status. (Option D) A white blood cell count of 15,000/mm³ (15.0 × 10⁹/L) is elevated (normal: 4,000-11,000/mm³ [4.0-10.0 × 11⁹/L]), which indicates that the infection has not resolved. Educational objective: The best assessment finding for indicating improved nutritional status is a steady weight gain over a specified period. Serum prealbumin is a faster and more reliable indicator of current nutritional status than serum albumin.

Question 7

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss.  The nurse's response is based on an understanding of which of the following?

Accepted Answer

11ecbb05_c99a_848d_b433_0fdce381dcf9_MD0009_00 Fasting for more than 1 or 2 days can cause a number of health problems: Increased stress - when fasting, the body goes into "starvation mode;" metabolism slows down and cortisol production increases Muscle damage - in starvation mode, the body breaks down muscle and converts amino acids to glucose Fluid loss - glycogen stores in the liver are also broken down as an energy source; this metabolic process releases water, resulting in fluid loss Increased hunger - appetite hormones are suppressed during a fast; however, when regular eating habits are resumed, appetite will be increased Depletion of essential nutrients Fatigue, headache, dehydration, dizziness, and muscle weakness (Option A) Fasting for more than 1 or 2 days can lead to health problems. (Option B) In starvation mode, the body will use protein, fat, and stored carbohydrates as energy sources. Protein is not spared. (Option C) Appetite may be suppressed during a fast after the first few hours/days; however, when regular intake is resumed, hunger will return. Educational objective: Fasting can cause multiple health problems, including increased stress, slowing of the body's metabolism, muscle damage, fluid loss, increased hunger, depletion of nutrients, and physical symptoms such as headache, dizziness, fatigue, and muscle weakness.

Question 8

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.

Accepted Answer

11ecbb05_c998_afcc_b433_c7e14db12f4a_MD0009_00 Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter (LES) normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the LES (eg, caffeine, alcohol), delays gastric emptying (eg, fatty foods), or increases gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may prevent GERD and associated symptoms include: Weight loss, as excessive abdominal fat may increase gastric pressure Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals (Option C) Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options A, D, and E) Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated Refraining from eating at bedtime and/or lying down immediately after eating (Option B) Clients with GERD generally do not need to minimize or eliminate dairy products from the diet; however, they should choose low-fat or nonfat products. Educational objective: Lifestyle and dietary measures that help prevent or minimize symptoms of gastroesophageal reflux disease include avoiding dietary triggers such as alcohol, caffeine, chocolate, peppermint, and high-fat foods. Clients should consume small, frequent meals and discontinue the use of tobacco products.

Question 9

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply.

Accepted Answer

11ecbb05_c995_7b7a_b433_c9e212fd4bb5_MD0009_00 Following a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time. Recommendations to delay gastric emptying include: Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than carbohydrates (Option A). These foods also help meet the body's energy needs. Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsens symptoms. Fluid intake should occur up to 30 minutes before or after meals. Slowly consume small, frequent meals to reduce the amount of food in the stomach (Option C). Avoid meals high in simple carbohydrates (eg, sugar, syrup) because these may trigger symptoms when the carbohydrates break down into simple sugars. Avoid sitting up after a meal because gravity increases gastric emptying. Instead, lying down after meals is encouraged (Option E). (Option B) Avoid meals high in simple carbohydrates because these may trigger dumping syndrome. (Option D) Avoid consuming fluids with meals to reduce the risk of dumping syndrome. Educational objective: Dumping syndrome is a complication of gastrectomy. To delay gastric emptying and reduce the risk of dumping syndrome, clients should consume meals low in carbohydrates and high in fiber, proteins, and fats; avoid fluids during meals; eat small, frequent meals; and lie down after eating.

Question 10

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply.

Accepted Answer

11ecbb05_c993_3188_b433_f57379db5e53_MD0009_00 Cardinal symptoms of acute cholecystitis from cholelithiasis include pain in the RUQ with referred pain to the right shoulder and scapula (Option E). Clients often report fatty food ingestion 1-3 hours before the initial onset of pain. Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia (Option C). During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone(s) obstruction of the cystic bile duct. The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign; palpation over the RUQ causes pain and inability to take a deep breath. Laboratory results show leukocytosis. (Option A) Flank pain radiating to the groin is seen with renal colic (ureteral stones). (Option B) It is not dietary protein but food with significant fat content (cheese, avocado, fried foods, hamburger) that signals the gallbladder to contract, emptying bile into the duodenum to help digestion. Gallstones normally harmlessly floating around the gallbladder are squeezed into the bile duct, causing the pain of biliary colic. Gallstones stuck further down the bile duct may become colonized by a bacterial infection (choledocholithiasis). (Option D) Initial onset of pain at the umbilicus is seen with acute appendicitis. Educational objective: Cardinal symptoms of acute calculous cholecystitis include pain in the RUQ and referred pain to the right shoulder and scapula a few hours after eating fatty foods. Associated symptoms include fever, chills, nausea, vomiting, and anorexia.

Question 11

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings.  Which of the following findings would indicate that the client is developing refeeding syndrome?

Accepted Answer

Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually (Option B) These values are within normal ranges for phosphorus (2.4-4.4 mg/dL [0.78-1.42 mmol/L]), potassium (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and magnesium (1.5-2.5 mEq/L [0.75-1.25 mmol/L]). In refeeding syndrome, the values for one or more of these electrolytes are decreased. (Option C) These laboratory values are below normal ranges but are not associated with refeeding syndrome. (Option D) These are normal laboratory values and are not associated with refeeding syndrome. Educational objective: Refeeding syndrome is a serious complication of nutritional replenishment. It is marked by declines in serum phosphorus, potassium, and/or magnesium (mnemonic PPM). Clients can also develop fluid overload. Low-calorie feedings and a gradual increase in calories can prevent refeeding syndrome. Electrolytes should be monitored frequently.

Question 12

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply.

Accepted Answer

In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. Shortness of breath occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm (Option B). In semi-Fowler position, the head of the bed is elevated 30-45 degrees; in Fowler position, elevation is 45-60 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruritus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours (Option D). A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies (Option E). (Option A) This client has ascites and peripheral edema; higher levels of fluid or sodium intake can worsen these conditions. (Option C) In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate shortness of breath by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion. Educational objective: The client with discomfort and shortness of breath due to ascites should be positioned in the semi-Fowler or Fowler position to promote comfort and lung expansion. Music and other methods of distraction may also promote comfort. Meticulous skin interventions (eg, specialty mattress, turning schedule) are important to prevent tissue breakdown.

Question 13

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL (11.65 mmol/L). What is the priority action by the nurse?

Accepted Answer

Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity (Option A). Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously. (Option B) The client's chills and rebound tenderness are signs of infection that require further assessment. Dialysate is typically warmed to body temperature before instillation to prevent abdominal discomfort and increase urea clearance through vessel dilation. Dry heating with a heating cabinet or incubator rather than a microwave is recommended to reduce the danger of burning the peritoneum. The dwell time is based on the prescribed dialysis method and should not be extended without a prescription. (Option C) High Fowler's position can help reduce shortness of breath if the client has volume overload, but it may worsen abdominal pain. (Option D) Glucose (dextrose) is the osmotic agent in dialysate. Therefore, glucose levels must be monitored closely, particularly in clients with diabetes. However, a glucose level of 210 mg/dL (11.65 mmol/L) does not necessitate IV administration of regular insulin. Regular insulin can be added to the dialysate before the solution is instilled, or it can be administered subcutaneously to control glucose levels. Educational objective: Peritonitis is a common but serious complication of peritoneal dialysis. Manifestations include cloudy effluent, fever, abdominal pain, and rebound tenderness. Treatment is based on culture of the peritoneal fluid.

Question 14

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.

Accepted Answer

A client with cirrhosis may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum). The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching (Options B and E). Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin (Options A and D). Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications. (Option C) Temperature extremes (eg, hot baths/showers) may intensify pruritus. The nurse should instruct the client to bathe with tepid water until the pruritus has subsided. Educational objective: A client with cirrhosis may experience pruritus (itching) due to the buildup of bile salts beneath the skin. Comfort measures include encouraging the client to cut nails short and wear long-sleeved cotton shirts and cotton gloves. Baking soda baths, calamine lotion, and cool, wet cloths also help. Cholestyramine increases the excretion of bile salts through feces, thereby decreasing itching.

Question 15

The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test. Place the steps for completing this test in the correct sequence. All options must be used.

Accepted Answer

11ecbb05_c993_cdc9_b433_636ad1eaafe3_MD0009_00 The guaiac fecal occult blood test is used to assess for microscopic blood in the stool as a screening tool for colorectal cancer. The steps for collecting a sample include: Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere and produce false test results. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves (Option B). Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from 2 different areas of the specimen as some portions of the stool may not contain microscopic blood (Option D). Close the slide cover and allow the stool specimen to dry for 3-5 minutes. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide (Option C). Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn the test paper blue, indicating presence of microscopic blood in the stool (Option E). Dispose of used gloves and the wooden applicator and perform hand hygiene. Document the results (Option A). Educational objective: The guaiac fecal occult blood test detects microscopic blood in the stool and is used to screen for colorectal cancer. A blue color on the Hemoccult slide paper within 30-60 seconds indicates a positive result.

Question 16

A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statements by the nurse correctly answer the client's question? Select all that apply.

Accepted Answer

Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: Clear liquid diet the day before Nothing by mouth 8-12 hours prior to the examination The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health status. (Option B) Healthy clients screened for colon disease do not require antibiotics prior to the procedure. (Option C) The instructions prior to a nuclear gastric emptying scan include teaching the client to avoid smoking the day of the examination as delay of gastric emptying occurs with tobacco use. Smoking cessation per se has no role in colonoscopy, but it is good for general health. Educational objective: Instructions for clients scheduled for a colonoscopy include a clear liquid diet the day before the procedure, avoiding any food or liquids (nothing by mouth) 8-12 hours prior to the examination, and taking the bowel-cleansing agent as prescribed.

Question 17

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse?

Accepted Answer

Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option A) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option C) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option D) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN. Educational objective: The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.

Question 18

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

Accepted Answer

Hepatic encephalopathy is a serious complication of end-stage liver disease (ESLD) that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy. The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by assessing for asterixis and comparing current mental status and ammonia level to previous findings. If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and discharge should be delayed until the client is stable. (Option D) The client with lethargy and confusion is at risk for falling. Ambulation is not an appropriate intervention at this point. (Option E) Lactulose is the primary drug used for hepatic encephalopathy treatment. It helps to excrete ammonia through the bowels as soft or loose stools. Lactulose should not be held if the client's hepatic encephalopathy continues to worsen. Educational objective: Hepatic encephalopathy is a serious complication of end-stage liver disease caused by high levels of ammonia in the blood. Assessment findings include confusion, lethargy, and asterixis; coma and death can occur if this condition remains untreated. Pharmacologic treatments include lactulose and antibiotics (eg, rifaximin). The client with worsening encephalopathy is not stable enough for discharge.

Question 19

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?

Accepted Answer

This client with celiac disease continues to have symptoms. An assessment of the client's food intake must be obtained to determine if it includes foods that contain gluten, a protein in barley, rye, oats, and wheat (mnemonic: BROW). The most common reason for non-responsiveness to a gluten-free diet in clients with celiac disease is that gluten has not been entirely eliminated from their food intake. (Option A) Referral to a dietitian is an appropriate intervention. However, the nurse must first explore why the client is not responding to therapy. This is not the first or best response by the nurse. (Option B) Most people experience dramatic relief of gastrointestinal symptoms within a few days of eliminating gluten from their diet. (Option D) This is a non-therapeutic response that "blames" the client for symptoms. In addition, this conclusion cannot be made without an assessment of the client's intake. Educational objective: When a client with celiac disease does not experience symptom relief after being on a gluten-free diet, it is most important for the nurse to assess the underlying cause. The most common reason for refractory symptoms is failure to follow the strict gluten-free diet.

Question 20

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply.

Accepted Answer

11ecbb05_c997_503b_b433_3d7d9742c26c_MD0009_00 Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula). Diverticulosis is characterized by the presence of these protrusions; the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce the risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past, clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that avoidance of these foods will prevent an episode of diverticulitis. (Option C) A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. (Option E) Increased consumption of red meat and other high-fat foods can increase the risk of diverticulitis. Educational objective: Clients with diverticulosis should take measures to prevent constipation (eg, high-fiber diet, increased fluid intake, regular exercise), which may help prevent recurring episodes of acute diverticulitis.

Exam 1: Adult Health

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement?

The nurse is admitting a client with cholelithiasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority?

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission. Which foods would be the best for this client?

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider?

A client is admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom?

An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment?

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss. The nurse's response is based on an understanding of which of the following?

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply.

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply.

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome?

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply.

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.

The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test. Place the steps for completing this test in the correct sequence. All options must be used.

A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statements by the nurse correctly answer the client's question? Select all that apply.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN) , are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse?

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply.