Nursing Elites

1. 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.

2. The client with Crohn’s disease has a nursing diagnosis of Acute Pain. The nurse would teach the client to avoid which of the following in managing this problem?

• A. Lying supine with the legs straight
• B. Massaging the abdomen
• C. Using antispasmodic medication
• D. Using relaxation techniques

Correct answer: A

Rationale: In managing acute pain associated with Crohn’s disease, the client should avoid lying supine with the legs straight. This position increases muscle tension in the abdomen, potentially aggravating inflamed intestinal tissues as the abdominal muscles are stretched. Massaging the abdomen, using antispasmodic medication, and employing relaxation techniques are beneficial in alleviating pain. Massaging can help relax abdominal muscles, antispasmodic medication can reduce spasms contributing to pain, and relaxation techniques aid in overall pain management. Therefore, choices B, C, and D are appropriate interventions for managing pain in clients with CroCrohn’s disease.

3. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

• A. 1/16”
• B. 1/4″
• C. 1/2”
• D. 1”

Correct answer: A

Rationale: When teaching a patient how to use a colostomy, only 1/16” of skin should remain exposed between the stoma and the ring of the appliance to prevent skin irritation.

4. Which of the following symptoms indicates diverticulosis?

• A. No symptoms exist
• B. Change in bowel habits
• C. Anorexia with low-grade fever
• D. Episodic, dull, or steady midabdominal pain

Correct answer: A

Rationale: Diverticulosis often has no symptoms and is usually found incidentally during tests for other conditions.

5. Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

• A. Fluid and electrolyte balance
• B. Gastric irrigation
• C. Pain management
• D. Psychosocial issues

Correct answer: A

Rationale: The priority focus of nursing management for a client with peritonitis is fluid and electrolyte balance to prevent shock.

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