Nursing Elites

1. The nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of Acute Pain. The nurse would determine that the client has not met the expected outcomes if the client states

• A. That pain is relieved with histamine H2 receptor antagonists.
• B. That irritating foods have been eliminated from the diet.
• C. The client is being awakened at 2 AM with heartburn.
• D. The client has absence of pain before meals.

Correct answer: C

Rationale: Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.

2. A client with which of the following conditions may be likely to develop rectal cancer?

• A. Adenomatous polyps
• B. Diverticulitis
• C. Hemorrhoids
• D. Peptic ulcer disease

Correct answer: A

Rationale: Adenomatous polyps are a known risk factor for the development of rectal cancer.

3. 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.

4. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I’m not sure I can avoid alcohol.' The most appropriate response is

• A. Everything will be alright.
• B. I think you should talk more with the doctor about this.
• C. I don’t believe that.
• D. I’m not sure that I don’t understand. Would you please explain?

Correct answer: D

Rationale: The most appropriate response in this situation is to seek clarification from the client by saying, 'I’m not sure that I don’t understand. Would you please explain?' This response shows empathy and a willingness to listen, encouraging the client to elaborate on their concerns. False reassurance (Choice A) is not helpful as it dismisses the client's feelings. Suggesting to talk more with the doctor (Choice B) may deflect from addressing the client's immediate concerns. Expressing disbelief (Choice C) can create a barrier to open communication, making the client feel unsupported.

5. The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:

• A. Check that the hemostat is on the bedside
• B. Monitor IV fluids for the shift
• C. Regularly assess respiratory status
• D. Check that the balloon is deflated on a regular basis

Correct answer: C

Rationale: Regularly assessing respiratory status is crucial when a Sengstaken-Blakemore tube is inserted to control bleeding in esophageal varices.

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