ATI Care of Patients with Inflammatory Intestinal Disorders, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis?

a.            Severe, steady right lower quadrant (RLQ) pain

b.            Abdominal pain that started a day after vomiting began

c.             Abdominal pain that increases with knee flexion

d.            Marked peristalsis and hyperactive bowel sounds

ANS: A

Right lower quadrant pain, specifically at McBurney’s point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 1267

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the client’s temperature is 101.1° F (38.4° C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority?

a.            A “left shift” in the white blood cell count

b.            White blood cell count, 22,000/mm3

c.             Serum sodium, 149 mEq/L

d.            Serum creatinine, 0.7 mg/dL

ANS: B

This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the provider’s attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)

3. The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse?

a.            Monitor vital signs.

b.            Maintain IV fluids.

c.             Provide perineal care.

d.            Initiate Isolation Precautions.

ANS: B

Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

4. The nurse is caring for a client who is having approximately 20 foul-smelling stools each day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organism does the nurse expect to see in the culture report?

a.            Helicobacter pylori

b.            Campylobacter jejuni

c.             Clostridium botulinum

d.            Norwalk virus

ANS: B

Campylobacter gastroenteritis causes foul-smelling diarrhea with up to 20 to 30 stools per day for 7 days. Both RBCs and WBCs are present in a Gram stain of the stools. Infection with Clostridium causes not diarrhea, but constipation, paralysis, and respiratory failure. H. pylori is a common cause of gastric ulcers, not gastroenteritis. Norwalk virus produces milder illness with diarrhea and vomiting.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction does the nurse provide to the client?

a.            “Drink plenty of fluids to prevent dehydration.”

b.            “You can have only clear liquids to drink.”

c.             “Milk products will give you extra protein.”

d.            “You can have sips of cola or tea to relieve nausea.”

ANS: A

The client should drink plenty of fluids to prevent dehydration. Clients are not necessarily restricted to clear liquids. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Teaching/Learning

6. The nurse provides discharge teaching for a client who was hospitalized for Salmonella food poisoning. Which client statement indicates that additional teaching is needed?

a.            “I will let my husband do the cooking for my family.”

b.            “I will take the ciprofloxacin (Cipro) until the diarrhea has resolved.”

c.             “I will wash my hands with antibacterial soap before and after each meal.”

d.            “I will make sure that my dishes go straight into the dishwasher after each meal.”

ANS: B

Cipro should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonellashould not prepare foods for others because the infection may be spread in this way. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Clients can be carriers for up to 1 year.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

7. The nurse is caring for a client who is hospitalized with exacerbation of Crohn’s disease. What does the nurse expect to find during the physical assessment?

a.            Positive Murphy’s sign with rebound tenderness

b.            Dullness in the lower abdominal quadrants

c.             High-pitched, rushing bowel sounds in the right lower quadrant

d.            Abdominal cramping that the client says is worse at night

ANS: C

The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn’s disease. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn’s disease. Nightly worsening of abdominal cramping is not consistent with Crohn’s disease. A positive Murphy’s sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

8. A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition?

a.            Potassium, 5.5 mEq/L

b.            Hemoglobin, 14.2 g/dL

c.             Sodium, 144 mEq/L

d.            Erythrocyte sedimentation rate (ESR), 55 mm/hr

ANS: D

The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)