Preview Extract
Chapter 45
1. Acyclovir (Zovirax) ointment has been prescribed for a client with oral herpes lesions. The
nurse includes the following information when educating the client regarding this medication:
Select all that apply.
1. Adverse effects include vomiting and diarrhea.
2. It can reduce the length of the herpes outbreak.
3. It is an antibiotic medication.
4. Repeated usage of the drug will likely put the client into a permanent remission state.
5. It is most effective when administered intravenously.
Answer: 1. Adverse effects include vomiting and diarrhea.
2. It can reduce the length of the herpes outbreak.
Rationale:
Adverse effects include vomiting and diarrhea. Adverse effects include headache, nausea,
vomiting, and diarrhea. It can reduce the length of the herpes outbreak. Acyclovir is used to
reduce the severity and length of an outbreak of herpes simplex. It is an antibiotic medication.
Acyclovir is an antiviral agent. Repeated usage of the drug will likely put the client into a
permanent remission state. Herpes simplex is a viral condition that is not curable, and
outbreaks are likely to occur when the client is physically and/or emotionally stressed. It is
most affective when administered intravenously. For patients with intact immune systems,
oral acyclovir (Zovirax) is generally used.
2. A client diagnosed with oral cancer has undergone surgery to manage the condition,
resulting in scarring both inside and outside of the oral cavity. The nurse developing the plan
of care identifies which of the following nursing diagnoses as having highest priority?
1. Nutrition, Imbalanced: more than body requirements, risk for
2. Body Image, Disturbed
3. Communication: impaired, verbal
4. Knowledge Deficient regarding causative factor of disease process
Answer: Nutrition, Imbalanced: more than body requirements, risk for
Rationale:
While each of the nursing diagnoses listed is appropriate for the client, nutrition has the
highest priority because it affects wound healing and general health. Deferring to Maslow’s
hierarchy, the physiological diagnoses would have the highest priority.
3. A client who has been diagnosed with a bacterial stomatitis affecting his tongue and buccal
areas has been reporting oral pain of 6 out of 10. The nurse educates the client regarding the
appropriate use of a 2% viscous lidocaine topical medication by encouraging the client to:
1. Use the medication every 3 hours as needed for oral pain control.
2. Swallow the medication after swishing it thoroughly in his mouth.
3. Refrain from eating or drinking for ½ hour after using the medication.
4. Rinse his mouth with an alcohol-based mouthwash prior to using the medication.
Answer: Use the medication every 3 hours as needed for oral pain control.
Rationale:
The nurse should inform the patient that the lidocaine may be used every 3 hours as needed.
The nurse should ensure that the patient rinses his mouth with the viscous lidocaine, then
spits it out, because swallowing the solution may impair the ability to swallow. Using
lidocaine just prior to meals may help improve oral intake. Mouthwash containing alcohol
should be avoided because it may increase the irritation already present in the mouth.
4. The client has been diagnosed with gastroesophageal reflux (GERD) that has resulted from
a relaxation of the lower esophageal sphincter (LES). When providing instructions to assist
with managing the condition, the nurse includes:
Select all that apply.
1. Limit last food intake to 4 hours before bedtime.
2. Eat largest meal of the day at midday.
3. Sleep in a bed with the head elevated 6 to 8 inches.
4. Develop a daily exercise routine.
5. Include a caffeinated beverage with meals.
Answer: 1. Limit last food intake to 4 hours before bedtime.
2. Eat largest meal of the day at midday.
3. Sleep in a bed with the head elevated 6 to 8 inches.
4. Develop a daily exercise routine.
Rationale:
Limit last food intake to 4 hours before bedtime. The patient should avoid eating anything
within 4 hours of bedtime. Eat largest meal of the day at midday. It is often helpful to eat
small frequent meals, with the largest meal at midday. Sleep in a bed with the head elevated 6
to 8 inches. The head of the bed should be elevated. Develop a daily exercise routine. A
regular exercise program such as daily walking can promote digestion. Include a caffeinated
beverage with meals. Caffeine has been shown to lower LES pressure and so should be
avoided.
5. Discharge teaching for the client with peptic ulcer disease (PUD) is being planned. The
nurse includes the following in the educational information provided to the client:
Select all that apply.
1. Good hand-washing practices will minimize the risk of transmission to family.
2. Implement strategies to discontinue the use of any tobacco product.
3. Check with health care provider before taking over-the-counter medications containing
aspirin.
4. Follow a bland, low-fat, high-protein diet with six small meals daily.
5. Avoid ingestion of any form of alcoholic beverage.
Answer: 1. Good hand-washing practices will minimize the risk of transmission to family.
2. Implement strategies to discontinue the use of any tobacco product.
3. Check with health care provider before taking over-the-counter medications containing
aspirin.
Rationale:
Good hand-washing practices will minimize the risk of transmission to family. Because H.
pylori is found in saliva and feces, increasing the possibility of person-to-person transmission
through oral-to-oral and fecal-to-oral routes, good hand hygiene should be encouraged.
Implement strategies to discontinue the use of any tobacco product. The rate of healing is
slowed and the recurrence rate of PUD is increased in patients who smoke or use tobacco
products, so nicotine use should be discouraged. Check with health care provider before
taking over-the-counter medications containing aspirin. The patient should be advised not to
take NSAIDs or aspirin (or products containing aspirin—e.g., Excedrin, Alka-Seltzer)
without first discussing the situation with the healthcare provider. Follow a bland, low-fat,
high-protein diet with six small meals daily. There are no specific dietary modifications that
an individual with PUD should follow because no food is considered ulcerogenic. Avoid
ingestion of any form of alcoholic beverage. Small amounts of alcohol do not cause harm, but
large amounts should be avoided.
6. The nurse is caring for a client diagnosed with achalasia who will be receiving a botulinum
toxin (Botox) injection to help improve function of his lower esophageal sphincter (LES)
muscle. The nurse includes education to reinforce to the client that this medical intervention
will:
1. Usually be effective for 6 to 9 months.
2. Require dilation of the esophagus.
3. Require general anesthesia.
4. Likely result in dysphagia.
Answer: Usually be effective for 6 to 9 months.
Rationale:
A less invasive procedure for achalasia is performed with the injection of botulinum toxin
(Botox) into the LES through an endoscopic procedure using conscious sedation. The
disadvantage of this procedure is that it usually requires repeated treatment every 6 to 9
months. The traditional treatment of achalasia has been the use of esophageal dilation or
myotomy. Dysphagia is a result of the condition, not a side effect of the Botox treatment.
7. The nurse recognizes that the symptomology of celiac disease in adults includes:
Select all that apply.
1. Rheumatoid arthritis.
2. Chronic hepatitis.
3. Osteoporosis.
4. Peptic ulcer disease.
5. Chronic constipation.
Answer: 1. Rheumatoid arthritis.
2. Chronic hepatitis.
3. Osteoporosis.
Rationale:
Rheumatoid arthritis. Most adults have signs and symptoms that are unrelated to the GI tract,
such as symptoms of rheumatoid arthritis. Chronic hepatitis. Most adults have signs and
symptoms that are unrelated to the GI tract, such as symptoms of chronic hepatitis.
Osteoporosis. Most adults have signs and symptoms that are unrelated to the GI tract, such as
symptoms of osteoporosis. Peptic ulcer disease. PUD is not typically associated with celiac
disease. Chronic constipation. Chronic constipation is not typically associated with celiac
disease.
8. The nurse recognizes that the client diagnosed with celiac disease needs further education
regarding the disease process when the client states:
1. “I treat myself to a ham and cheese on rye with a light beer once a week.”
2. “It’s really difficult to maintain my gluten-free lifestyle.”
3. “The only way to truly diagnose this disease it through a biopsy of my small intestine.”
4. “The trouble I’m having with the enamel on my teeth is a result of this disease.”
Answer: “I treat myself to a ham and cheese on rye with a light beer once a week.”
Rationale:
The client with celiac disease is incapable of appropriately reacting to ingested gluten and so
is placed on a gluten-free diet. Gluten is found in wheat, barley, and rye. Many foods do
contain gluten, and so it is difficult to maintain such a diet. A biopsy of the small intestine is
the gold standard for diagnosing celiac disease, and dental enamel hypoplasia is a sign often
seen in clients with this disease.
9. A 28-year-old female client is diagnosed with inflammatory disease of the small bowel.
When the client describes numerous daily bowel movements but denies the presence of
bloody stool, the nurse realizes that this client was most likely diagnosed with:
1. Crohn’s disease.
2. Ulcerative colitis.
3. Chronic diarrhea.
4. Gastroenteritis.
Answer: Crohn’s disease.
Rationale:
Crohn’s disease is an inflammatory disease of the small bowel that does not present bloody
stool as a common characteristic sign. Ulcerative colitis affects the large intestine. Neither
chronic diarrhea nor gastroenteritis is necessarily characterized by bloody stool.
10. A client is hospitalized during an acute exacerbation of symptoms related to Crohn’s. The
nurse shows an understanding of the need for bowel rest by discussing with the client that he:
1. Will be receiving total parenteral nutrition (TPN).
2. Will be getting only a soft diet until the diarrhea subsides.
3. Should select foods that are high in potassium.
4. May find a high-calorie, low-fat, high-fiber diet helpful.
Answer: Will be receiving total parenteral nutrition (TPN).
Rationale:
During an acute exacerbation of IBD, particularly Crohn’s disease, the patient is allowed no
food taken orally. During this period of “bowel rest,” total parenteral nutrition (TPN) is
usually prescribed.
11. The nurse is reviewing the dietary recommendations with a client recovering from an
acute episode of diverticular disease. The nurse identifies the following for inclusion in the
discussion:
Select all that apply.
1. Incorporating both soluble and insoluble fiber into the daily diet.
2. Ingesting at least 25 to 30 grams of fiber daily as is recommended for adults.
3. Eating oatmeal-based cereals as breakfast and snack foods.
4. Avoiding eating fresh grapes because the skins can be problematic.
5. Including raisins in the diet as a good source of iron to offset poor iron absorption.
Answer: 1. Incorporating both soluble and insoluble fiber into the daily diet.
2. Ingesting at least 25 to 30 grams of fiber daily as is recommended for adults.
3. Eating oatmeal-based cereals as breakfast and snack foods.
4. Avoiding eating fresh grapes because the skins can be problematic.
Rationale:
Incorporating both soluble and insoluble fiber into the daily diet. Once the acute phase has
passed, dietary recommendations include eating a diet high in both soluble and insoluble
fiber. Ingesting at least 25 to 30 grams of fiber daily as is recommended for adults. The
recommended fiber consumption for the general public of the United States is 25 to 30 grams
and should be stressed for the person with diverticular disease. Eating oatmeal-based cereals
as breakfast and snack foods. Oatmeal is a high-fiber food recommended for patients with
diverticular disease. Avoiding eating fresh grapes because the skins can be problematic. For
patients with diverticular disease, foods containing small seeds, nuts, and foods with skins
such as grapes are restricted because they may become lodged in a diverticulum and cause
inflammation and an exacerbation of diverticulitis. Including raisins in the diet as a good
source of iron to offset poor iron absorption. For patients with diverticular disease, foods
containing small seeds, nuts, and foods with skins such as raisins are restricted, because they
may become lodged in a diverticulum and cause inflammation and an exacerbation of
diverticulitis.
12. The nurse is preparing information to be included in a community educational
presentation regarding gastroesophageal reflux disease (GERD). The decision is made to
include the following:
Select all that apply.
1. GERD is more prevalent in adults over the age of 50.
2. A substantial number of people self-medicate with OTC medications.
3. Control of the symptoms is dependent on a change of diet.
4. A reoccurring sore throat may be a symptom of the disease.
5. Vomiting is a common sign of the disease.
Answer: 1. GERD is more prevalent in adults over the age of 50.
2. A substantial number of people self-medicate with OTC medications.
3. Control of the symptoms is dependent on a change of diet.
4. A reoccurring sore throat may be a symptom of the disease.
Rationale:
GERD is more prevalent in adults over the age of 50. The incidence of gastroesophageal
reflux disease (GERD) increases after age 50, but it can occur at any age and the prevalence
is equal across gender, ethnic, and cultural groups. A substantial number of people selfmedicate with OTC medications. It is believed that the number of people experiencing reflux
may actually be much higher, but because many H2-receptor blockers are available without a
prescription, a large number of cases go unreported. Control of the symptoms is dependent on
a change of diet. Lifestyle modifications including diet are key in the treatment of GERD.
Many patients may have total symptom relief through these efforts alone. A reoccurring sore
throat may be a symptom of the disease. Atypical symptoms include asthma or a sore throat.
Vomiting is a common sign of the disease. Gastroesophageal reflux is the backward flow of
stomach contents (chyme) into the esophagus without associated vomiting.
13. The nurse is assessing a client who is reporting symptoms similar to those associated with
gastroesophageal reflux disease (GERD). The nurse inquires as to whether the client is
currently prescribed:
1. Inderal.
2. Valium.
3. Birth control pills.
4. Bronchodilator.
5. Nitroglycerine.
Answer: 1. Inderal.
2. Valium.
3. Birth control pills.
4. Bronchodilator.
Rationale:
Inderal. The nurse should assess for medications such as beta-adrenergic blockers (Inderal).
Valium. The nurse should assess for medications such as diazepam (Valium). Birth control
pills. The nurse should assess for medications such as estrogen and progesterone.
Bronchodilator. The nurse should assess for medications such as bronchodilators
(Theophylline). Nitroglycerine. There is no known connection between nitroglycerine and the
symptoms of GERD.
14. A client with cancer of the rectum is scheduled for surgery and the placement of a
permanent ostomy. The nurse includes discussion of which of the following types of ostomies
in the client’s presurgical education plan?
1. Sigmoid
2. Duodenal
3. Double-barrel
4. Transverse loop
Answer: Sigmoid
Rationale:
A sigmoid colostomy is the most common permanent colostomy performed, particularly for
cancer of the rectum. The duodenal, double-barrel, and transverse loop colonoscopy are not
in the correct area to manage cancer in this location.
Cognitive Level Application
15. A client who has been diagnosed with a form of gastric carcinoma shows concern about
the prospects of her adult children having the disease. Which of the following questions asked
by the nurse shows an understanding of the disease?
1. “Have any of your children ever been treated for a stomach ulcer?”
2. “Are any of your children particularly fond of eating bacon, hot dogs, or luncheon meats?”
3. “Have your children ever been tested for colon cancer?”
4. “Do any of your children smoke either cigarettes or cigars?”
5. “Are any of your children exhibiting signs of depression or obsessive compulsive
disorder?”
Answer: 1. “Have any of your children ever been treated for a stomach ulcer?”
2. “Are any of your children particularly fond of eating bacon, hot dogs, or luncheon meats?”
3. “Have your children ever been tested for colon cancer?”
Rationale:
“Have any of your children ever been treated for a stomach ulcer?” Helicobacter pylori (H.
pylori), a bacterium causing gastritis, is thought to be related to the development of gastric
cancer. “Are any of your children particularly fond of eating bacon, hot dogs, or luncheon
meats?” Nitrates found in smoked meats, bacon, lunch meats, and hot dogs have been linked
to the development of gastric cancer as well. “Have your children ever been tested for colon
cancer?” Gastric cancer is one of the most common inherited cancer syndromes. “Do any of
your children smoke either cigarettes or cigars?” Research has not shown any definitive links
between smoking and the occurrence of gastric cancer. “Are any of your children exhibiting
signs of depression or obsessive compulsive disorder?” Research has not shown any
definitive links between depression or OCD and the occurrence of gastric cancer.
16. To best minimize the client’s risk of developing a postsurgical infection at the site of a
permanent colostomy, the nurse:
1. Changes the dressing as ordered by the surgeon.
2. Instructs the client in the proper technique for handling hygiene of the colostomy site.
3. Administers intravenous antibiotics as prescribed.
4. Assesses the client’s understanding of the importance of infection control measures.
Answer: Changes the dressing as ordered by the surgeon.
Rationale:
Changing the dressing as ordered by the surgeon will have the greatest impact on keeping the
incision clean and dry and helps prevent an infection at the site. Instructing the client
regarding proper hygiene techniques is more relevant to long-term prevention of infections.
IV antibiotics, while appropriate, will not have the same degree of impact as does good
wound care. The client’s understanding of the importance of infection control is more
relevant to long-term prevention of infections.
17. A nasointestinal tube (NI) has been inserted into a client diagnosed with an intestinal
obstruction. Which of the following statements made by the nurse caring for the client
indicates a lack of understanding regarding the nursing care required for safe management of
this medical intervention?
1. “It’s my habit to irrigate nasointestinal tubes (NI) just prior to administering the client’s
sleeping medication.”
2. “The client has been very compliant about remaining on his right side.”
3. “The placement of the tubing has been confirmed by x-ray, so now I’ll attach it to low
intermittent suction.”
4. “I’ll ambulate the client at least twice before bedtime to help advance the tube.”
Answer: “It’s my habit to irrigate nasointestinal tubes (NI) just prior to administering the
client’s sleeping medication.”
Rationale:
The tube is not irrigated unless ordered by the health care provider. Once inserted into the
stomach, position the patient on his right side. The health care provider may order the tube to
be advanced 2 to 4 inches at a time or to let gravity move the tube into the small intestine.
Movement of the patient, either ambulation or changing positions in bed, will assist the
forward movement of the tube. Low intermittent suction may be ordered once placement is
confirmed by x-ray.
18. The nurse recognizes that a risk factor for developing a strangulated intestinal hernia is a
history of:
1. Surgical adhesions.
2. Familiar occurrence.
3. Intestinal infarctions.
4. Hyperlipidemia.
Answer: Surgical adhesions.
Rationale:
In a strangulated bowel obstruction, there is an interruption of blood flow, both venous and
arterial, by mechanical means, which can result from surgical adhesions. There is no research
to support a genetic link or an increased risk related to high blood cholesterol levels.
Impairment of arterial blood flow resulting from the strangulation leads to ischemic
infarctions.
19. A client is being assessed for a possible bowel obstruction. The nurse provides the client
with information regarding diagnostics to confirm the presence of an obstruction that include:
Select all that apply.
1. An abdominal x-ray series.
2. A CT scan of the abdomen.
3. CBC with differential.
4. Serum osmolality.
5. Barium swallow.
Answer: 1. An abdominal x-ray series.
2. A CT scan of the abdomen.
Rationale:
An abdominal x-ray series. Confirmation of the diagnosis can be made by x-rays. A CT scan
of the abdomen. Confirmation of the diagnosis can be made by CT scan. CBC with
differential. The laboratory tests, although not diagnostic, will be done to determine the
presence of infection and/or dehydration. Serum osmolality. The laboratory tests, although
not diagnostic, will be done to determine the presence of infection and/or dehydration.
Barium swallow. A barium swallow is contraindicated because of the possibility of intestinal
perforation or a worsening of the obstruction.
20. During a follow-up visit 4 weeks after gastric resection surgery, a client reports
experiencing cramping, nausea, and diarrhea within 10 minutes after eating. The nurse
suspects that the client is experience “dumping syndrome” and suggests that he:
Select all that apply.
1. Increase the protein in his diet.
2. Lie down for 30 minutes immediately after eating.
3. Eat frequent, small meals.
4. Reduce the amount of carbohydrates eaten daily.
5. Drink a glass of water prior to each meal.
Answer: 1. Increase the protein in his diet.
2. Lie down for 30 minutes immediately after eating.
3. Eat frequent, small meals.
4. Reduce the amount of carbohydrates eaten daily.
Rationale:
Increase the protein in his diet. Increasing the amount of protein and fat in the diet will help
slow the transit time. Lie down for 30 minutes immediately after eating. The patient should
be instructed to lie down for 30 to 60 minutes after eating to slow transit time. Eat frequent,
small meals. The symptoms can be managed by eating small, more frequent meals. Reduce
the amount of carbohydrates eaten daily. Carbohydrates should be reduced in order to help
slow the transit time. Drink a glass of water prior to each meal. Drinking before eating
actually might intensify the problem.
21. A client who has had gastric surgery that affected the effectiveness of his alimentary
system will be fed via a gastrostomy tube upon his discharge to home. The nurse recognizes
that the primary reason for this means of nutrition is that it is:
1. Less likely to produce side effects than parenteral nutrition.
2. Less invasive than a jejunostomy tube.
3. More cost effective than nasogastric feeding.
4. More supportive of the specialized diet the client will require.
Answer: Less likely to produce side effects than parenteral nutrition.
Rationale:
The purpose of a gastrostomy tube is to provide complete nutrition through the alimentary
system. It is safer and has fewer side effects than total parenteral nutrition (TPN), particularly
when the patient is to have feedings at home. The gastrostomy tube is as invasive as the
jejunostomy tube. It is not necessarily more cost effective than nasogastric feeding, nor is it
more appropriate for specialized feeding needs.
22. A client diagnosed with peptic ulcer disease (PUD) asks the nurse whether it is likely that
surgery will be required to successfully treat this condition. The nurse shows an
understanding of this disease process when responding:
1. “The administration of the appropriate medications makes surgery rarely necessary.”
2. “Surgery is required in about 50% of the cases.”
3. “Surgery has a higher success rate than medication therapy alone.”
4. “If you take your medications and follow the prescribed diet, surgery isn’t usually needed.”
Answer: “The administration of the appropriate medications makes surgery rarely necessary.”
Rationale:
Fortunately, with the discovery of H. pylori infection as the major cause of peptic ulcers, and
the development of medications to eradicate this organism, surgery is rarely necessary. The
success rate of pharmacologic intervention is to eradicate H. pylori is 75% to 90%. There are
no specific dietary modifications for PUD.
23. The nurse tells the client that his newly created permanent ileostomy:
1. Will initially produce dark green fecal matter.
2. Will require additional surgery in 2 to 3 months.
3. Was necessary when his condition required a gastroduodenostomy (Billroth I).
4. Should not produce any bloody discharge.
Answer: Will initially produce dark green fecal matter.
Rationale:
Initially the ileostomy will produce effluent that is dark green and viscous, gradually turning
yellow-brown. A permanent ileostomy does not generally require follow-up surgery.
Immediately postoperative there may be small amounts of blood. An ileostomy is not the
outcome of a gastroduodenostomy (Billroth I).
24. The nurse’s instructions to a client with a newly created Koch ileostomy (continent
ileostomy) include:
Select all that apply.
1. The surgery involved manipulating a portion of the terminal ileum.
2. A nipple valve was created to control the flow of fecal matter.
3. The stoma should appear pink and moist.
4. Fecal matter will be removed by a catheter inserted through the stoma.
5. The stoma will be reversed when the bowels have had the time to heal.
Answer: 1. The surgery involved manipulating a portion of the terminal ileum.
2. A nipple valve was created to control the flow of fecal matter.
3. The stoma should appear pink and moist.
4. Fecal matter will be removed by a catheter inserted through the stoma.
Rationale:
The surgery involved manipulating a portion of the terminal ileum. A continent ileostomy,
also known as Kock ileostomy or Kock pouch, involves the terminal ileum being folded back
on itself and the inner wall removed, thereby forming a reservoir and a nipple valve. The end
is then brought through the abdominal wall to form a stoma. A nipple valve was created to
control the flow of fecal matter. The nipple valve prevents leaking of fecal contents through
the stoma. The stoma should appear pink and moist. The stoma should appear pink and moist.
Fecal matter will be removed by a catheter inserted through the stoma. The reservoir is
emptied by a catheter inserted through the stoma. The stoma will be reversed when the
bowels have had the time to heal. This is not generally a reversible, temporary procedure.
25. Good skin and stomal integrity is a goal included in the care plan of a client with a
colostomy. The evaluation parameters best suited for this goal includes:
Select all that apply.
1. Stoma pink and moist.
2. No excoriation noted on skin surrounding stoma.
3. Client shows understanding of importance of preventing fecal leakage.
4. Client demonstrates ability to apply collecting appliance properly.
5. Stomal area is free of pain.
Answer: 1. Stoma pink and moist.
2. No excoriation noted on skin surrounding stoma.
Rationale:
Stoma pink and moist. Evaluation parameters for the stated goal are: Stoma pink and moist
and Skin surrounding stoma pink, no excoriation. No excoriation noted on skin surrounding
stoma. Evaluation parameters for the stated goal are: Stoma pink and moist and Skin
surrounding stoma pink, no excoriation. Client shows understanding of importance of
preventing fecal leakage. Evaluation parameters for the stated goal are: Stoma pink and moist
and Skin surrounding stoma pink, no excoriation. Client demonstrates ability to apply
collecting appliance properly. This is not related to skin integrity but rather client
understanding of the condition and pain. Stomal area is free of pain. This is not related to skin
integrity but rather client understanding of the condition and pain.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
