Nursing Elites

1. In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?

• A. The client passes formed stools at regular intervals
• B. The client reports a decrease in stool frequency and liquidity
• C. The client exhibits firm skin turgor
• D. The client no longer experiences perianal burning

Correct answer: C

Rationale: Firm skin turgor indicates adequate hydration, which is a key goal of fluid resuscitation. Formed stools, decreased stool frequency, and relief from perianal burning are important but do not directly indicate successful fluid resuscitation.

2. 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?

• A. Constipation.
• B. Bloody, diarrheal stools.
• C. Steatorrhea.
• D. Alternating periods of constipation and diarrhea.

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.

3. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?

• A. Increase the amount of sodium in the diet.
• B. Limit the amount of fluids consumed.
• C. Encourage frequent ambulation.
• D. Administer magnesium antacids.

Correct answer: B

Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.

4. In a client with Crohn’s disease, which of the following symptoms should not be a direct result from antibiotic therapy?

• A. Decrease in bleeding
• B. Decrease in temperature
• C. Decrease in body weight
• D. Decrease in the number of stools

Correct answer: C

Rationale: Decrease in body weight is not a direct result of antibiotic therapy but may occur due to the underlying disease process.

5. A client with ulcerative colitis is diagnosed with a mild case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets?

• A. High-fat with milk
• B. High-protein without milk
• C. Low-roughage without milk
• D. Low-roughage with milk

Correct answer: C

Rationale: The client with a mild case of ulcerative colitis is often advised to follow a diet low in roughage and avoid milk. This dietary approach helps reduce the frequency of diarrhea in these clients. Therefore, the correct therapeutic diet for the client with ulcerative colitis in this scenario is a low-roughage diet without milk. Choices A, B, and D are incorrect because high-fat, high-protein, and low-roughage with milk diets are not typically recommended for clients with ulcerative colitis, especially those with mild cases.

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