Nur 114 Exam 2 (Colon
Cancer/Elimination/Inflammation) – Questions
With Comprehensive Solutions
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Terms in this set (88)
Jordin is a client with Answer: D
jaundice who is
experiencing pruritus. The client with pruritus experiences itching, which may
Which nursing intervention lead to skin breakdown and possibly infection from
would be included in the scratching. Keeping his fingernails short and smooth
care plan for the client? helps prevent skin breakdown and infection from
A. Administering vitamin K scratching. Applying pressure when giving I.M.
subcutaneously injections and administering vitamin K subcutaneously
are important if the client develops bleeding problems.
B. Applying pressure when Decreasing the client's dietary intake is appropriate if
giving I.M. injections the client's ammonia levels are increased.
C. Decreasing the client's
dietary protein intake
D. Keeping the client's
fingernails short and
smooth
,Marie, a 51-year-old Answer: C
woman, is diagnosed with
cholecystitis. Which diet, For the client with cholecystitis, fat intake should be
when selected by the reduced. The calories from fat should be substituted
client, indicates that the with carbohydrates. Reducing carbohydrate intake
nurse's teaching has been would be contraindicated. Any diet high in fat may lead
successful? to another attack of cholecystitis.
A. 4-6 small meals of low-
carbohydrate foods daily
B. High-fat, high-
carbohydrate meals
C. Low-fat, high-
carbohydrate meals
D. High-fat, low protein
meals
The hospital administrator Answer: A
had undergone
percutaneous transhepatic Septicemia is a common complication after a
cholangiography. which percutaneous transhepatic cholangiography. Evidence
assessment finding of fever and chills, possibly indicative of septicemia, is
indicates complication after important. HYpotension, not hypertension, is associated
the operation? with septicemia. Tachycardia, not bradycardia, is most
A. Fever and chills likely to occur. Nausea and diarrhea may occur but are
B. Hypertension not classic signs of sepsis.
C. Bradycardia
D. Nausea and diarrhea
,For Jayvin who is taking Answer: B
antacids, which instruction
would be included in the Antacids neutralize gastric acid and decrease the
teaching plan? absorption of other medications. The client should be
A. "Take the antacids with 8 instructed to avoid taking other medications within 2
oz of water." hours of the antacid. Water, which dilutes the antacid,
should not be taken with antacid. A histamine receptor
B. "Avoid taking other antagonist should be taken even when pain subsides.
medications within 2 hours Daily weights are indicated if the client is taking a
of this one." diuretic, not an antacid.
C. "Continue taking
antacids even when pain
subsides."
D. "Weigh yourself daily
when taking this
medication.
Which clinical manifestation Answer: D
would the nurse expect a
client diagnosed with acute Acute cholecystitis is an acute inflammation of the
cholecystitis to exhibit? gallbladder commonly manifested by the following:
A. Jaundice, dark urine, and anorexia, nausea, and vomiting; biliary colic; tenderness
steatorrhea and rigidity the right upper quadrant (RUQ) elicited on
palpation (e.g., Murphy's sign); fever; fat intolerance;
B. Acute right lower and signs and symptoms of jaundice. Ecchymosis,
quadrant (RLQ) pain, petechiae, and coffee-ground emesis are clinical
diarrhea, and dehydration manifestations of esophageal bleeding. The coffee-
ground appearance indicates old bleeding. Jaundice,
C. Ecchymosis petechiae, dark urine, and steatorrhea are clinical manifestations of
and coffee-ground emesis the icteric phase of hepatitis
D. Nausea, vomiting, and
anorexia
, Pierre who is diagnosed Answer: C
with acute pancreatitis is
under the care of Nurse With acute pancreatitis, the client is kept on nothing-by-
Bryan. Which intervention mouth status to inhibit pancreatic stimulation and
should the nurse include in secretion of pancreatic enzymes. NG intubation with
the care plan for the client? low intermittent suction is used to relieve nausea and
vomiting, decrease painful abdominal distention, and
A. Administration of remove hydrochloric acid. Vasopressin would be
vasopressin and insertion appropriate for a client diagnosed with bleeding
of a balloon tamponade esophageal varices. Paracentesis and diuretics would be
appropriate for a client diagnosed with portal
B. Preparation for a hypertension and ascites. A low-fat diet and increased
paracentesis and fluid intake would further aggravate the pancreatitis
administration of diuretics
C. Maintenance of nothing-
by-mouth status and
insertion of nasogastric
(NG) tube with low
intermittent suction
D. Dietary plan of a low-fat
diet and increased fluid
intake to 2,000 ml/day
For Rico who has chronic Answer: B
pancreatitis, which nursing
intervention would be most Chronic pancreatitis typically results from repeated
helpful? episodes of acute pancreatitis. More than half of
A. Allowing liberalized fluid chronic pancreatitis cases are associated with
intake alcoholism. Counseling to stop alcohol consumption
B. Counseling to stop would be the most helpful for the client. Dietary protein
alcohol consumption modification is not necessary for chronic pancreatitis.
C. Encouraging daily Daily exercise and liberalizing fluid intake would be
exercise helpful but not the most beneficial intervention.
D. Modifying dietary
protein
Cancer/Elimination/Inflammation) – Questions
With Comprehensive Solutions
Save
Terms in this set (88)
Jordin is a client with Answer: D
jaundice who is
experiencing pruritus. The client with pruritus experiences itching, which may
Which nursing intervention lead to skin breakdown and possibly infection from
would be included in the scratching. Keeping his fingernails short and smooth
care plan for the client? helps prevent skin breakdown and infection from
A. Administering vitamin K scratching. Applying pressure when giving I.M.
subcutaneously injections and administering vitamin K subcutaneously
are important if the client develops bleeding problems.
B. Applying pressure when Decreasing the client's dietary intake is appropriate if
giving I.M. injections the client's ammonia levels are increased.
C. Decreasing the client's
dietary protein intake
D. Keeping the client's
fingernails short and
smooth
,Marie, a 51-year-old Answer: C
woman, is diagnosed with
cholecystitis. Which diet, For the client with cholecystitis, fat intake should be
when selected by the reduced. The calories from fat should be substituted
client, indicates that the with carbohydrates. Reducing carbohydrate intake
nurse's teaching has been would be contraindicated. Any diet high in fat may lead
successful? to another attack of cholecystitis.
A. 4-6 small meals of low-
carbohydrate foods daily
B. High-fat, high-
carbohydrate meals
C. Low-fat, high-
carbohydrate meals
D. High-fat, low protein
meals
The hospital administrator Answer: A
had undergone
percutaneous transhepatic Septicemia is a common complication after a
cholangiography. which percutaneous transhepatic cholangiography. Evidence
assessment finding of fever and chills, possibly indicative of septicemia, is
indicates complication after important. HYpotension, not hypertension, is associated
the operation? with septicemia. Tachycardia, not bradycardia, is most
A. Fever and chills likely to occur. Nausea and diarrhea may occur but are
B. Hypertension not classic signs of sepsis.
C. Bradycardia
D. Nausea and diarrhea
,For Jayvin who is taking Answer: B
antacids, which instruction
would be included in the Antacids neutralize gastric acid and decrease the
teaching plan? absorption of other medications. The client should be
A. "Take the antacids with 8 instructed to avoid taking other medications within 2
oz of water." hours of the antacid. Water, which dilutes the antacid,
should not be taken with antacid. A histamine receptor
B. "Avoid taking other antagonist should be taken even when pain subsides.
medications within 2 hours Daily weights are indicated if the client is taking a
of this one." diuretic, not an antacid.
C. "Continue taking
antacids even when pain
subsides."
D. "Weigh yourself daily
when taking this
medication.
Which clinical manifestation Answer: D
would the nurse expect a
client diagnosed with acute Acute cholecystitis is an acute inflammation of the
cholecystitis to exhibit? gallbladder commonly manifested by the following:
A. Jaundice, dark urine, and anorexia, nausea, and vomiting; biliary colic; tenderness
steatorrhea and rigidity the right upper quadrant (RUQ) elicited on
palpation (e.g., Murphy's sign); fever; fat intolerance;
B. Acute right lower and signs and symptoms of jaundice. Ecchymosis,
quadrant (RLQ) pain, petechiae, and coffee-ground emesis are clinical
diarrhea, and dehydration manifestations of esophageal bleeding. The coffee-
ground appearance indicates old bleeding. Jaundice,
C. Ecchymosis petechiae, dark urine, and steatorrhea are clinical manifestations of
and coffee-ground emesis the icteric phase of hepatitis
D. Nausea, vomiting, and
anorexia
, Pierre who is diagnosed Answer: C
with acute pancreatitis is
under the care of Nurse With acute pancreatitis, the client is kept on nothing-by-
Bryan. Which intervention mouth status to inhibit pancreatic stimulation and
should the nurse include in secretion of pancreatic enzymes. NG intubation with
the care plan for the client? low intermittent suction is used to relieve nausea and
vomiting, decrease painful abdominal distention, and
A. Administration of remove hydrochloric acid. Vasopressin would be
vasopressin and insertion appropriate for a client diagnosed with bleeding
of a balloon tamponade esophageal varices. Paracentesis and diuretics would be
appropriate for a client diagnosed with portal
B. Preparation for a hypertension and ascites. A low-fat diet and increased
paracentesis and fluid intake would further aggravate the pancreatitis
administration of diuretics
C. Maintenance of nothing-
by-mouth status and
insertion of nasogastric
(NG) tube with low
intermittent suction
D. Dietary plan of a low-fat
diet and increased fluid
intake to 2,000 ml/day
For Rico who has chronic Answer: B
pancreatitis, which nursing
intervention would be most Chronic pancreatitis typically results from repeated
helpful? episodes of acute pancreatitis. More than half of
A. Allowing liberalized fluid chronic pancreatitis cases are associated with
intake alcoholism. Counseling to stop alcohol consumption
B. Counseling to stop would be the most helpful for the client. Dietary protein
alcohol consumption modification is not necessary for chronic pancreatitis.
C. Encouraging daily Daily exercise and liberalizing fluid intake would be
exercise helpful but not the most beneficial intervention.
D. Modifying dietary
protein
