Nursing Elites

1. 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.

2. Which of the following diets is most commonly associated with colon cancer?

• A. Low-fiber, high fat
• B. Low-fat, high-fiber
• C. Low-protein, high-carbohydrate
• D. Low carbohydrate, high protein

Correct answer: A

Rationale: A low-fiber, high-fat diet is most commonly associated with an increased risk of colon cancer.

3. A client who has had gastrectomy is not producing sufficient intrinsic factor. The nurse interprets that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in the

• A. Stomach.
• B. Small intestine.
• C. Large intestine.
• D. Colon.

Correct answer: B

Rationale: Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. Vitamin B12 is not absorbed in the large intestine (options 3 and 4).

4. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor increases as a result of vagotomy?

• A. Peristalsis.
• B. Gastric acidity.
• C. Gastric motility.
• D. Gastric pH.

Correct answer: D

Rationale: After a gastric vagotomy, the gastric pH increases as a result of reduced acid secretion.

5. 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.

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