a client with viral hepatitis states i am so yellow the nurse most appropriately would
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

2. To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?

Correct answer: C

Rationale: To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.

3. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:

Correct answer: D

Rationale: A vagotomy reduces the stimulus to acid secretions by cutting the vagus nerve, which innervates the stomach.

4. Hepatic encephalopathy develops when the blood level of which substance increases?

Correct answer: A

Rationale: Hepatic encephalopathy develops when the blood level of ammonia increases.

5. Radiation therapy is used to treat colon cancer before surgery for which of the following reasons?

Correct answer: A

Rationale: Radiation therapy is used before surgery to reduce the size of the tumor, making it easier to remove.

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