Nursing Elites

1. Which of the following conditions can cause a hiatal hernia?

• A. Increased intrathoracic pressure
• B. Weakness of the esophageal muscle
• C. Increased esophageal muscle pressure
• D. Weakness of the diaphragmic muscle

Correct answer: D

Rationale: Weakness of the diaphragmic muscle can lead to a hiatal hernia as it allows part of the stomach to push through the diaphragm into the chest cavity.

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: Lying supine with the legs straight can increase abdominal tension and exacerbate pain. The client should be advised to lie with the legs bent to reduce muscle tension and discomfort.

3. You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?

• A. Administering a lactulose enema as ordered.
• B. Encouraging a protein-rich diet.
• C. Administering sedatives, as necessary.
• D. Encouraging ambulation at least four times a day.

Correct answer: A

Rationale: Administering a lactulose enema as ordered helps reduce ammonia levels in patients with hepatic encephalopathy.

4. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:

• A. Decreases food absorption in the stomach
• B. Heals the gastric mucosa
• C. Halts stress reactions
• D. Reduces the stimulus to acid secretions

Correct answer: D

Rationale: A vagotomy reduces the stimulus to acid secretions by cutting the vagus nerve, which innervates the stomach.

5. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

• A. Distilled water
• B. Tap water
• C. Sterile water
• D. Lactated Ringer’s

Correct answer: B

Rationale: Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.

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