Chapter 38 Osborn, Medical-Surgical Nursing, 2e

Question 1 Type: MCSA The nurse should instruct the patient with a diagnosis of cholelithiasis to make which lifestyle modification to alleviate symptoms? 1. Reduce sodium intake. 2. Increase fluids. 3. Reduce smoking. 4. Reduce fat consumption. Correct Answer: 4 Rationale 1: While all patients should be instructed to reduce sodium intake, this practice will not assist in reducing cholelithiasis or its pain. Rationale 2: Increasing fluids will not assist in reducing cholelithiasis or its pain. Rationale 3: While all patients should cease smoking, there is no relationship between smoking and cholelithiasis. Rationale 4: The patient who has cholelithiasis should be instructed on the relationship between increased fatconsumption and the severity of pain associated with cholelithiasis. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38-1 Question 2 Type: MCSA When assessing a patient who has cirrhosis, which finding would best indicate the patient is developing ascites? 1. Accumulation of fluid in the abdomen 2. Yellow skin 3. Ecchymosis 4. Upper-right-quadrant pain Correct Answer: 1 Rationale 1: Ascites is the accumulation of the fluid in the abdomen and is a result of portal hypertension. Rationale 2: Yellow skin is a manifestation of jaundice and is associated with hepatic disorders. Rationale 3: The patient experiencing hepatic problems might have bleeding and bruising issues due to inadequate vitamin K. Rationale 4: Obstructed biliary flow could be the cause of upper-right-quadrant pain.Global Rationale: