Nursing Elites

1. The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions most specifically would elicit information regarding the pain that is associated with acute pancreatitis?

• A. Does the pain in your abdomen radiate to your groin.
• B. Does the pain in your stomach radiate to the back?
• C. Does the pain in your stomach radiate to your lower middle abdomen?
• D. Does the pain in your lower abdomen radiate to the hip?

Correct answer: B

Rationale: The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to the back. Options 1, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

2. A nurse is reviewing the results of serum laboratory studies drawn on a client who is suspected of having hepatitis. The nurse interprets that an elevation in which of the following studies is the most specific indicator of the disease?

• A. Erythrocyte sedimentation rate
• B. Serum bilirubin
• C. Hemoglobin
• D. Blood urea nitrogen

Correct answer: C

Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

3. The client with a duodenal ulcer may exhibit which of the following findings on assessment?

• A. Hematemesis
• B. Malnourishment
• C. Melena
• D. Pain with eating

Correct answer: C

Rationale: Melena (black, tarry stools) can be an indication of a duodenal ulcer.

4. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, “I know that I have colon cancer, too.” Which response is most therapeutic?

• A. I know just how you feel.
• B. You seem upset.
• C. Oh, don’t worry about it, everything will be just fine.
• D. Why do you think you have cancer?

Correct answer: B

Rationale: Acknowledging the patient's emotions with 'You seem upset' is the most therapeutic response.

5. An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?

• A. Prepare 750 ml of irrigating solution warmed to 100*F
• B. Question the physician about the order
• C. Provide privacy and explain the procedure to the client
• D. Assist the client to left lateral Sim’s position

Correct answer: B

Rationale: An enema is contraindicated in clients with suspected appendicitis because it can increase the risk of perforation. It is important to verify the appropriateness of this order with the physician.

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