Nursing Elites

1. Which goal of the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

• A. Promoting self-care and independence
• B. Managing diarrhea
• C. Maintaining adequate nutrition
• D. Promoting rest and comfort

Correct answer: B

Rationale: Managing diarrhea should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis.

2. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

• A. A reservoir is created that exits through the abdominal wall.
• B. A second surgery is required 12 months after the first surgery.
• C. A permanent ileostomy is created.
• D. The surgery occurs in two stages.

Correct answer: D

Rationale: The surgery to create an ileoanal reservoir occurs in two stages.

3. A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?

• A. Severe abdominal pain relieved by vomiting
• B. Severe abdominal pain that is unrelieved by vomiting
• C. Hypothermia
• D. Epigastric pain radiating to the neck area

Correct answer: B

Rationale: A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.

4. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?

• A. Asterixis
• B. Chvostek’s sign
• C. Trousseau’s sign
• D. Hepatojugular reflex

Correct answer: A

Rationale: Asterixis, a flapping tremor of the hands, is a sign of hepatic encephalopathy.

5. A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?

• A. Spider angiomas
• B. Fatigue
• C. Pale urine
• D. Weight gain

Correct answer: B

Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.

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