short bowel syndrome usually occurs when

ATI RN

ATI RN Custom Exams Set 4

1. Short-bowel syndrome usually occurs when:

A. The longitudinal muscles of the intestine contract
B. More than 50% of the small intestine is surgically removed
C. More than 50% of the large intestine is surgically removed
D. Transit time is decreased due to infection or drugs

Correct answer: B

Rationale: Short-bowel syndrome usually occurs when more than 50% of the small intestine is surgically removed. This condition results in malabsorption of nutrients and fluids due to the reduced length of the small intestine. Choice A is incorrect because the contraction of longitudinal muscles does not lead to short-bowel syndrome. Choice C is incorrect as short-bowel syndrome is primarily related to the small intestine, not the large intestine. Choice D is incorrect since decreased transit time due to infection or drugs is not a direct cause of short-bowel syndrome.

2. Patients with gallbladder disease should reduce their intake of:

A. Protein
B. Sodium
C. Cholesterol
D. Fat

Correct answer: D

Rationale: Patients with gallbladder disease are advised to reduce their fat intake because fats can trigger gallbladder symptoms such as pain and bloating. While protein, sodium, and cholesterol may also impact overall health, reducing fat intake specifically helps manage gallbladder-related symptoms effectively. Protein is important for tissue repair, sodium can affect blood pressure, and cholesterol levels impact heart health, but in the context of gallbladder disease, fat reduction is the most beneficial.

3. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

A. Monitor the urine for bright-red bleeding
B. Evaluate the calorie count of the 500-mg protein diet
C. Assess the client’s sacrum for dependent edema
D. Monitor for a high serum albumin level

Correct answer: C

Rationale: Assessing the client’s sacrum for dependent edema is crucial in the care plan for nephritic syndrome as it is common due to protein loss. Dependent edema occurs as a result of decreased oncotic pressure from protein loss in the urine. Monitoring urine for bright-red bleeding (choice A) is more relevant to conditions like glomerulonephritis. Evaluating calorie count or protein intake (choice B) is important for other conditions but not specifically for nephritic syndrome. Monitoring for a high serum albumin level (choice D) is not typically part of the immediate care plan for nephritic syndrome.

4. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?

A. 32-year-old with diarrhea for 6 hours
B. 2-year-old with 1 wet diaper in 24 hours
C. 40-year-old with abdominal cramping
D. 10-year-old who is nauseated

Correct answer: B

Rationale: In cases of food poisoning, a 2-year-old with reduced urine output is a critical finding indicating dehydration, requiring immediate attention to prevent complications. The reduced urine output is a sign of decreased fluid intake or increased fluid loss, putting the child at high risk for dehydration. This client should be seen first to assess hydration status, initiate necessary interventions, and prevent further complications. While the other symptoms presented by the other clients are concerning, the 2-year-old's decreased urine output poses the most immediate threat to their well-being.

5. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?

A. Monitor the urine for bright-red bleeding
B. Evaluate the calorie count of the 500-mg protein diet
C. Assess the client’s sacrum for dependent edema
D. Monitor for a high serum albumin level

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with rule-out nephritic syndrome is to assess the client’s sacrum for dependent edema. Dependent edema is common in nephritic syndrome due to protein loss, and monitoring for this helps manage the condition. Choices A, B, and D are incorrect. Monitoring the urine for bright-red bleeding may be more relevant for a client with a different condition, such as glomerulonephritis. Evaluating the calorie count of a 500-mg protein diet is not directly related to managing nephritic syndrome. Monitoring for a high serum albumin level does not directly address the symptom of dependent edema associated with nephritic syndrome.