Nursing Elites

1. During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?

• A. Concave, midline umbilicus
• B. Pulsation between the umbilicus and pubis
• C. Bowel sound frequency of 15 sounds per minute
• D. Absence of a bruit

Correct answer: B

Rationale: The presence of pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm, which is a serious condition and should be reported to the physician promptly. A concave, midline umbilicus is a normal finding. Bowel sound frequency can vary widely and is not a cause for concern at 15 sounds per minute. Absence of a bruit is a normal finding in an abdominal assessment and does not require reporting.

2. Which of the following substances is most likely to cause gastritis?

• A. Milk
• B. Bicarbonate of soda or baking soda
• C. Enteric-coated aspirin
• D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Correct answer: D

Rationale: The correct answer is D, Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to cause gastritis by irritating the stomach lining. Choice A, Milk, is unlikely to cause gastritis and is actually a common remedy for mild gastritis symptoms. Choice B, Bicarbonate of soda or baking soda, is often used to relieve heartburn and indigestion, not cause gastritis. Choice C, Enteric-coated aspirin, is less likely to cause gastritis compared to NSAIDs because the enteric coating helps protect the stomach lining from irritation.

3. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

• A. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
• B. Disturbed Sleep Pattern related to epigastric pain
• C. Ineffective Coping related to exacerbation of duodenal ulcer
• D. Activity Intolerance related to abdominal pain

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

4. The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the client's plan of care?

• A. Encourage regular use of antidiarrheal medications.
• B. Incorporate frequent rest periods into the client's schedule.
• C. Have the client maintain a high-fiber diet.
• D. Wear a gown when providing direct client care.

Correct answer: B

Rationale: It is important for the client to have frequent rest periods. Repeated episodes of diarrhea interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client is experiencing a severe exacerbation of ulcerative colitis, bed rest may be ordered. Antidiarrheal medications can be used selectively in ulcerative colitis but are not recommended for regular use as they can lead to colonic dilation. The client should maintain a low-residue, high-calorie, caffeine-free diet.

5. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?

• A. Now I can never get hepatitis again.
• B. I can safely give blood after 3 months.
• C. I’ll never have a problem with my liver again, even if I drink alcohol.
• D. My family knows that if I get tired and start vomiting, I may be getting sick again.

Correct answer: D

Rationale: Understanding that family needs to be aware of symptoms that may indicate a recurrence of hepatitis B shows proper understanding by the patient.

Similar Questions