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The client has developed late-stage cirrhosis. Which community resources does the nurse suggest to the client to help in managing the client's care?

Nutritionist
Chaplain
Support Group

The client is scheduled for a liver transplantation secondary to hepatitis C infection and is being transferred to the hepatic transplantation unit. The nurse collaborates with the other health care team members to modify the client's plan of care. What is the expected outcome for this client?

Failure of the transplanted organ if it becomes infected with hepatitis C

The client with a history of congestive heart failure and circulatory problems has recently been diagnosed with cirrhosis. The client asks the nurse how she could have developed cirrhosis when she does not drink and has no family history of alcoholism. What is the nurse's best response?

''Cardiovascular disease is known to be a major risk factor for development of cirrhosis.''

The adult male client involved in a monogamous heterosexual relationship is diagnosed with hepatitis C. The client tells the nurse that he is concerned that he might pass the virus on to his girlfriend. What is the nurse's best response?

''The rate of sexual transmission of hepatitis C is very low in a monogamous relationship.''

The client has developed abdominal ascites as a result of alcohol-induced cirrhosis. What type of diet is recommended for the client initially in an attempt to decrease the fluid accumulation in the abdominal cavity?

1 to 2g sodium diet

The client has been diagnosed with viral hepatitis. The client's sister tells the nurse that she is alarmed because the client has begun to exhibit signs of depression and is no longer interacting with family and friends. How does the nurse interpret this client's behavior?

This is an expected emotional response to the disease process.

The client scheduled to undergo a liver transplantation expresses a high level of anxiety about the possibility of complications related to the surgery. What information does the nurse relay to the client?

Complications are not unexpected and usually are treatable.

The client has cirrhosis of the liver. Which statement by the client indicates that further instruction is needed about the pathophysiology of the disease process?

''My liver is scarred, but the cells can regenerate themselves and repair the damage.''

Although the cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage

Which laboratory test results are most indicative of cirrhosis?

Thrombocytopenia and anemia

It is possible for the client with cirrhosis to experience a decrease in platelets and red blood cells.

The client has been diagnosed with cirrhosis. When considering potential complications of this disorder, what is the priority nursing diagnosis?

Potential for Injury related to risk of hemorrhage

The client has progressed into late-stage cirrhosis and has been placed on lactulose. Which adjustment to the client's home environment does the home health nurse make to manage side effects of the medication?

Availability of a bedside commode

Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet.

The client with cirrhosis has recently developed the complication of portal systemic encephalopathy and has just been discharged back into the home setting. Which intervention is the highest priority for the nurse to teach family members when the client demonstrates the first sign of encephalopathy?

Increase the daily dose of lactulose.

The client is scheduled for emergency injection sclerotherapy as treatment for bleeding esophageal varices. Which statement by the client shows an accurate understanding of the procedure?

'My varices will be injected with a sclerosing agent through a catheter.''

In injection sclerotherapy, the varices are injected with a sclerosing agent via a catheter to stop the bleeding.

The nurse is monitoring the client undergoing a paracentesis. Which changes in the client's status does the nurse immediately report to the physician?

Decreased blood pressure, increased heart rate

The health care worker believes that he may have been exposed to hepatitis A. Which intervention is highest priority to prevent him from developing the disease?

Going to the emergency department (ED) for administration of immunoglobulin

The client is planning on traveling outside the country and is being instructed on how to avoid contacting viral hepatitis. Which statement by the client indicates a need for further instruction?

''I should avoid any food washed or prepared with tap water, although I can use ice.''

The nurse is caring for the client who has experienced liver trauma. Which assessment findings are most indicative of hemorrhage and hypovolemic shock?

confusion
diaphoresis
hypotension
tachycardia
tachypnea

The client has been diagnosed with cancer of the liver. Which initial treatment option does the nurse expect to be ordered for the client?

Radiofrequency ablation

The client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complication of bile leakage and abscess formation?

Keep the T-tube in a dependent position.

Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis.

The nurse is caring for patients in the outpatient clinic. Which of these phone calls should the nurse return first?

A) From the patient with hepatitis A complaining of severe and ongoing itching
B) From the patient with severe ascites who has a temperature of 100.4° F (38° C)
C) From the patient with cirrhosis who has had a 3-pound weight gain over 2 days
D) From the patient with esophageal varices and mild right upper quadrant pain

B) From the patient with severe ascites who has a temperature of 100.4° F (38° C)

The patient with ascites and an elevated temperature may have spontaneous bacterial peritonitis, and the nurse should call this patient first. The other patients' data are not unusual for their diagnoses, although the nurse will need to assess these patients after calling the patient with ascites.

The RN has just received change-of-shift report on an inpatient medical unit. Which patient should the RN see first?

A) The patient with ascites who had a paracentesis 2 hours ago and is complaining of a headache
B) The patient with portal-systemic encephalopathy who has become increasingly difficult to arouse
C) The patient with hepatic cirrhosis and jaundice who has a hemoglobin of 10.9 g/dL and thrombocytopenia
D) The patient with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

B) The patient with portal-systemic encephalopathy who has become increasingly difficult to arouse

Which assessment finding obtained by the nurse for a patient with cirrhosis who has just had 1500 mL of fluid removed by paracentesis is most important to communicate to the physician?

The blood pressure is 88/46 mm Hg.

A patient with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action should the nurse take first?

A) Obtain the charts from the previous admission.
B) Listen for bowel sounds in all quadrants.
C) Obtain the pulse and blood pressure.
D) Ask about abdominal pain.

C) Obtain the pulse and blood pressure.

The young adult client has come to the emergency department (ED) with a stab wound to the abdomen. Once stabilized, the client is admitted to the general medical-surgical unit. Which nursing intervention is the highest priority for this client?

Assessing vital signs

Assessment of vital signs should be done first to determine the adequacy of the airway and circulation. Vital signs initially reveal the most about the client's condition.

The home health nurse is discussing community resources available to the client who is scheduled for a colostomy after being diagnosed with colorectal cancer (CRC). Which resource referral by the nurse is of greatest value to this client?

Enterostomal therapist

The home health nurse, who is assigned to the client with colorectal cancer after discharge, is teaching the client about care of the new colostomy. Which statement by the client demonstrates an accurate understanding of the nurse's instruction?

''I should check for leakage underneath my colostomy.''

You don't want it to tight, a dark or purplish stoma or red or scratched skin is not normal

The client has been suffering with constipation as a result of irritable bowel syndrome (IBS). After instructing the client about a management plan, which statement by the client demonstrates an accurate understanding of the nurse's instruction?

''I should make an effort to go for a walk every evening.''

Can't have caffeinated beverages, need fiber & fluid

The client asks the nurse to suggest ways for altering the diet to reduce the risk of colorectal cancer. Which dietary selection does the nurse suggest?

Steamed broccoli with turkey

contains low-fat meat and no refined carbohydrates.

The client's sister has recently been diagnosed with CRC and the client's brother died of CRC 5 years ago. The client asks the nurse if he will inherit the disease. What is the nurse's best response?

''The only way to know if you have a predisposition to CRC is with genetic testing.''

The enterostomal nurse is teaching the client with colorectal cancer how to care for a colostomy. Which statement by the client reflects an accurate understanding of the self-management that is needed?

''I will make certain that I always have an extra bag available.''

The client has been admitted to the hospital with colorectal cancer and is scheduled for colostomy surgery. Which statement by the nurse is the most helpful for this client?

''Tell me what worries you the most about this procedure.''

The older adult male client reports pain in the inguinal area that occurs while coughing. A bulge is present in the inguinal area that can be pushed back into the abdomen. Which type of hernia is this?

Reducible

The hernia is reducible because its contents can be pushed back into the abdominal cavity.

The client is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which statement by the client indicates the need for further teaching about this procedure?

'I will need to stay in the hospital overnight.''

The client with a family history of CRC regularly visits the health care provider to detect any signs of cancer early. Which laboratory result may be an indication of CRC in this client?

Elevated carcinoembryonic antigen

Hgb would decrease, occult blood would be present, increase in liver function

The client with CRC is 1 day postoperative after colostomy surgery. The client is very anxious about caring for the colostomy and is afraid that all the physician's instructions will be overwhelming. Which initial intervention by the nurse is of highest priority?

A) Encouraging the client to verbalize feelings about the colostomy and its required care
B) Scheduling a visit from a client who has a colostomy and is successfully caring for it
C) Encouraging the client to look at and touch the stoma
D) Instructing the client about the care of the colostomy

Encouraging the client to look at and touch the stoma

The nurse is caring for the client scheduled to be discharged after a bowel resection and colostomy. Which statement by the client demonstrates that further instruction is needed before discharge?

''I'll be able to drive in about 2 weeks.''

The client who has had a bowel resection and colostomy should avoid driving for 4 to 6 weeks.

The client is being evaluated in the ED for a possible small bowel obstruction. Which symptoms are most indicative of a small bowel obstruction?

Upper abdominal distention, metabolic alkalosis, and great degree of vomiting

The client has a bowel obstruction and receives a Levin tube in the ED. Which nursing intervention is the highest priority for this client?

A) Checking peristalsis by auscultating for bowel sounds with the suction connected
B) Attaching the Levin tube to continuous low suction
C) Flushing the Levin tube with saline every 24 hours
D) Attaching the Levin tube to intermittent low suction

D) Attaching the Levin tube to intermittent low suction

The Levin tube should only be attached to intermittent suction because it has no vent.

The client who has developed an intestinal obstruction has pain that has recently changed from a colicky intermittent type to a constant discomfort. Which nursing intervention is the highest priority?

A) Positioning the client in a high Fowler's position
B) Administering medication for pain
C) Preparing the client for emergency surgery
D) Changing nasogastric suction from intermittent to constant

C) Preparing the client for emergency surgery

The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention.

The nurse is teaching a plan of care to the client who has undergone a hemorrhoidectomy. Which statement by the client demonstrates a good understanding of the nurse's instruction?

"I should eat a diet high in fiber.''

The client with malabsorption syndrome asks the nurse what he may have done to cause the disorder to develop. What is the nurse's best response?

''It is the result of a flattening of the mucosa of the large intestine, so nothing you did could have caused it.''

The RN working on the medical-surgical unit has just received report about these four patients. Which patient should the RN assess first?

A) A patient who has returned to the unit after a colon resection with a new colostomy stoma, which is dark pink
B) A patient who has been admitted after a motor vehicle accident and has ecchymoses on both flanks
C) A patient with pneumonia who has abdominal distention and markedly decreased bowel tones
D) A patient with familial adenomatous polyposis (FAP) who is scheduled for a colonoscopy

B) A patient who has been admitted after a motor vehicle accident and has ecchymoses on both flanks

After an automobile accident, a patient is admitted to the emergency department with possible abdominal trauma. Which of these physician requests will the nurse implement first?

A) Take the patient for computed tomography of the abdomen.
B) Insert a nasogastric tube, and connect it to intermittent suction.
C) Start an IV line, and infuse normal saline at 200 mL/hr.
D) Obtain a complete blood count and coagulation panel.

Start an IV line, and infuse normal saline at 200 mL/hr.

The client is scheduled for discharge after surgery for inflammatory bowel disease (IBD). The client's case manager is arranging for home health care, and the client indicates that family members will be helping with care at home as well. What priority information does the nurse provide to these collaborating members?

Written and oral instructions regarding symptoms to report to the physician

The client is scheduled for discharge after surgery for IBD. The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and spouse regarding post-discharge care?

Ability to perform incision care and dressing changes

The client with a long history of osteoarthritis has an extensive incision after a colon resection and is experiencing a postoperative infection. The client's wound requires extensive irrigation and packing. Which priority intervention regarding the client's care does the nurse discuss with the health care provider?

Home health consultation for wound care

The client with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next?

Asks another client with a stoma who performs self-care to come and talk with the client

The client with an exacerbation of ulcerative colitis has been prescribed a low-residue diet. Which meal plan is best for this client?

A) Chef's salad
B) Scrambled eggs, white toast with margarine
C) Tuna salad sandwich on whole wheat bread
D) Fried chicken with rice, cooked green beans

B) Scrambled eggs, white toast with margarine

No raw veggies, whole wheats

The enterostomal nurse is teaching the client about caring for a new ileostomy. Which instruction is the priority for the nurse to teach this client?

Call the health care provider if the stoma has a bluish or pale look.

means its blood supply may be compromised, and the health care provider must be notified immediately.

The client with a long-term history of ulcerative colitis began experiencing massive bleeding and underwent emergency surgery for creation of an ileostomy. The client is deeply concerned that sex with his or her spouse will cease because of how the new ileostomy pouch system looks. Which is the nurse's best response?

''A change in position is all that should be needed for you to have sex with your spouse.''

The client has vague symptoms that indicate an acute inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease?

A) Abdominal pain relieved by bending the knees
B) Epigastric cramping
C) Chronic diarrhea, abdominal pain, and fever
D) Hypotension with vomiting

C) Chronic diarrhea, abdominal pain, and fever

Abd pain relieved by bending the knees is peritonitis
Epigastric cramping is appendicits

The client demonstrates manifestations of appendicitis. Peritonitis is also suspected. Which is the priority nursing intervention?

Preparing the client to undergo emergency surgery

The client has developed gastroenteritis while traveling outside the country. Which is the likely cause of the client's symptoms?

Ingestion of parasites in water

Which statement differentiating Crohn's disease from ulcerative colitis is true?

A) There are very few complications associated with Crohn's disease.
B) Clients with Crohn's disease experience about 20 loose bloody stools daily.
C) Clients with ulcerative colitis may experience hemorrhage.
D) The peak incidence of ulcerative colitis is between 15 and 40 years of age.

C) Clients with ulcerative colitis may experience hemorrhage.

The nurse is teaching the client with Crohn's disease about managing the disease with adalimumab (Humira). Which instruction about the treatment plan does the nurse emphasize to the client?

Avoid large crowds and anyone who is sick.

The client has had a total colectomy and a continent ileostomy was created. Which postoperative instruction does the nurse emphasize to this client?

A small dressing must be worn over the stoma.

The nurse is teaching the client about nutritional ways to help manage exacerbations of diverticulitis. Which instruction is best for this client?

Consume a low-fiber diet while diverticulitis is active. When inflammation resolves, consume a high-fiber diet.

The client has an anal fissure. Which nursing intervention best promotes perineal comfort in this client?

Using witch hazel wipes to relieve pain

The client has developed an Escherichia coli infection after recently attending summer camp. Which action would have been most effective in preventing this infection?

Avoiding swallowing water while swimming

An RN who usually works in the intensive care unit (ICU) is floated to the medical-surgical unit. Which of these patients will be best to assign to the float nurse?

A) A patient with an exacerbation of Crohn's disease who has a draining enterocutaneous fistula
B) A patient with ulcerative colitis who needs discharge teaching about the use of hydrocortisone enemas
C) A patient who has many questions about how to care for a newly created ileoanal reservoir
D) A patient with peritonitis who has just returned from surgery with multiple drains in place

D) A patient with peritonitis who has just returned from surgery with multiple drains in place

A home health patient complains of having severe diarrhea for the past 24 hours. Which nursing action can the RN delegate to the home health aide who assists the patient daily with self-care?

A) Instruct about the use of electrolyte-containing oral rehydration products.
B) Give loperamide (Imodium) 4 mg from the patient's medicine cabinet.
C) Check and report lying, sitting, and standing blood pressure and heart rate.
D) Teach the patient how to clean the perineal area after each loose stool.

C) Check and report lying, sitting, and standing blood pressure and heart rate.

The RN has just received a change-of-shift report about these four patients. Which patient should be assessed first?

A) A 20-year-old with ulcerative colitis who has had six liquid stools during the previous shift
B) A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F
C) A 56-year-old who has had a colon resection and whose colostomy bag does not have any stool in it
D) A 60-year-old admitted with acute gastroenteritis who is complaining of severe cramping and nausea

B) A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F

An 80-year-old patient who has had myalgia, nausea, vomiting, and diarrhea for 2 days is admitted to the medical-surgical unit with gastroenteritis. Which request by the health care provider should the nurse implement first?

A) Obtain stool specimen for culture and sensitivity.
B) Administer acetaminophen (Tylenol) 650 mg rectally.
C) Draw blood for complete blood count and electrolytes.
D) Give 5% dextrose in 0.45 normal saline at 125 mL/hr.

D) Give 5% dextrose in 0.45 normal saline at 125 mL/hr.

Which assessment finding in an obese patient who has been discharged 10 days after being hospitalized with peritonitis and having an exploratory laparotomy indicates a need for immediate action by the home health nurse?

A) The patient's temperature is 100.8° F (38.2° C).
B) The patient complains of pain when coughing.
C) The patient says, "I feel like the incision is splitting open."
D) The patient states, "I am too tired to ambulate very much."

C) The patient says, "I feel like the incision is splitting open."

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