a client is admitted with a diagnosis of ulcerative colitis which of the following symptoms should the nurse expect the client to report when respondi a client is admitted with a diagnosis of ulcerative colitis which of the following symptoms should the nurse expect the client to report when respondi
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Nursing Elites

ATI RN

Gastrointestinal System Nursing Exam Questions

1. A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?

Correct answer: B

Rationale: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. Constipation is not a sign or symptom of ulcerative colitis. Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. Alternating diarrhea and constipation is associated with irritable bowel syndrome.

2. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

3. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

Correct answer: B: Dyspnea.

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

4. What is the goal of applied behavior analysis?

Correct answer: B

Rationale: The correct answer is B: "eliminate undesirable behaviors and increase desirable responses." Applied behavior analysis aims to modify behavior by focusing on eliminating unwanted behaviors and reinforcing desirable ones. It does not primarily deal with changes in temperament (choice A), self-perception (choice C), or personality traits (choice D). The approach involves techniques such as reinforcement to target specific behaviors, rather than broader cognitive processes or personality characteristics.

5. What is the priority nursing intervention when caring for a neonate born with bladder exstrophy?

Correct answer: C

Rationale: The priority nursing intervention when caring for a neonate born with bladder exstrophy is to cover the defect with sterile plastic wrap. This intervention helps prevent infection and maintains a moist environment, promoting optimal healing and reducing the risk of complications.

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