Adult 1 final final Exam Questions With Complete Solutions
A 19-yr-old patient has familial adenomatous polyposis (FAP).
Which action will the nurse in the gastrointestinal clinic include
in the plan of care?
a. Obtain blood samples for DNA analysis.
b. Schedule the patient for yearly colonoscopy.c. Provide
preoperative teaching about total colectomy.d. Discuss lifestyle
modifications to decrease cancer risk. Correct Answers b.
Schedule the patient for yearly colonoscopy.
Rationsle:Patients with FAP should have annual colonoscopy
starting at age 16 years and usually have total colectomy by age
25 years to avoid developing colorectal cancer. DNA analysis is
used to make the diagnosis but is not needed now for this
patient. Lifestyle modifications will not decrease cancer risk for
this patient
A 19-yr-old woman is brought to the emergency department
with a knife handle protruding from her abdomen. What should
the nurse do during the initial assessment of the patient?
a. Remove the knife and assess the wound.
b. Determine the presence of Rovsing sign.
c. Check for circulation and tissue perfusion.
d. Insert a urinary catheter and assess for hematuria. Correct
Answers c. Check for circulation and tissue perfusion.
Rationale:The initial assessment is focused on determining
whether the patient has hypovolemic shock. The knife should
not be removed until the patient is in surgery, where bleeding
can be controlled. Rovsing sign is assessed in the patient with
suspected appendicitis. Assessment for bladder trauma is not
part of the initial assessment.
,A 19-yr-old women admitted with anorexia nervosa is 5 ft, 6 in
(163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal
hypokalemia and iron deficiency anemia. Which patient problem
has the highest priority?
A.Difficult coping
B.Disturbed body image
C.Impaired nurtitional status
D.Risk for electrolyte imbalance Correct Answers Risk for
electrolyte imbalance
Rationale:The patients hypokalemia may lead to life-threatening
cardiac dyshythmias. The other diagnosis are also appropriate
for this patient but are not associated with amidiate risk for fatal
complications.
A 20-yr-old women is being admitted with electrolyte disorders
of unknown etiology. Which assessment finding is most
important to report to the health care provider?
A. The patient uses laxitives daily
B.The patients knuckles are macerated
C.The patients serum potassium level is 2.9 mEq/L
D.The patient has a history of extreme weight Correct Answers
The patients serum potassium level is 2.9 mEq/L
Rationale: The low serum potassium level may cause life-
threatening cardiac dysrhthmias, and potassium supplementation
is needed rapidly
A 22-yr-old female patient with an exacerbation of ulcerative
colitis is having 15 to 20 stools daily and has excoriated perianal
skin. Which patient behavior indicates that teaching regarding
maintenance of skin integrity has been effective?
,a. The patient uses incontinence briefs to contain loose stools.
b. The patient uses witch hazel compresses to soothe irritation.
c. The patient asks for antidiarrheal medication after each stool.
d. The patient cleans the perianal area with soap after each stool.
Correct Answers b. The patient uses witch hazel compresses to
soothe irritation.Witch hazel compresses are suggested to reduce
anal irritation and discomfort.
A 25-yr-old male patient calls the clinic reporting diarrhea for
24 hours. Which action should the nurse take first?
a. Inform the patient that testing of blood and stools will be
needed.
b. Suggest that the patient drink clear liquid fluids with
electrolytes.
c. Ask the patient to describe the stools and any associated
symptoms.
d. Advise the patient to use over-the-counter antidiarrheal
medication. Correct Answers . Ask the patient to describe the
stools and any associated symptoms.
Rationale:The initial response by the nurse should be further
assessment of the patient. The other responses may be
appropriate, depending on what is learned in the assessment.
A 26-yr-old women is being evaluated for vomiting and
abdominal pain.Whuch question from the nurse will be most
useful in determining the cause of the patients symptoms?
A."What type of foods do you eat?"
B."Is it possible that you are pregnant?"
C."Can you tell me more about the pain?"
D."What is your usual elimination pattern?" Correct Answers
"Can you tell me more about the pain?"
, Rationale:A complete description of the pain provides cles about
the cause of the problem.
A 33-yr-old male patient with a gunshot wound to the abdomen
undergoes surgery, and a colostomy is formed as shown in the
accompanying figure. Which information will be included in
patient teaching?
a. Stool will be expelled from both stomas.
b. This type of colostomy is usually temporary.
c. Soft, formed stool can be expected as drainage.
d. Irrigations can regulate drainage from the stomas. Correct
Answers b. This type of colostomy is usually temporary.
Rationale:A loop, or double-barrel stoma, is usually temporary.
Stool will be expelled from the proximal stoma only. The stool
from the transverse colon will be liquid and regulation through
irrigations will not be possible.
A 40-yr-old male patient has had a herniorrhaphy to repair an
incarcerated inguinal hernia. Which patient teaching will the
nurse provide before discharge?
a. Soak in Sitz baths several times each day.
b. Cough 5 times each hour for the next 48 hours.
c. Avoid using acetaminophen (Tylenol) for pain.
d. Apply a scrotal support and ice to reduce swelling. Correct
Answers d. Apply a scrotal support and ice to reduce swelling.
Rationale:A scrotal support and ice are used to reduce edema
and pain. Coughing will increase pressure on the incision. Sitz
baths will not relieve pain and would not be of use after this
surgery. Acetaminophen can be used for postoperative pain.
A 19-yr-old patient has familial adenomatous polyposis (FAP).
Which action will the nurse in the gastrointestinal clinic include
in the plan of care?
a. Obtain blood samples for DNA analysis.
b. Schedule the patient for yearly colonoscopy.c. Provide
preoperative teaching about total colectomy.d. Discuss lifestyle
modifications to decrease cancer risk. Correct Answers b.
Schedule the patient for yearly colonoscopy.
Rationsle:Patients with FAP should have annual colonoscopy
starting at age 16 years and usually have total colectomy by age
25 years to avoid developing colorectal cancer. DNA analysis is
used to make the diagnosis but is not needed now for this
patient. Lifestyle modifications will not decrease cancer risk for
this patient
A 19-yr-old woman is brought to the emergency department
with a knife handle protruding from her abdomen. What should
the nurse do during the initial assessment of the patient?
a. Remove the knife and assess the wound.
b. Determine the presence of Rovsing sign.
c. Check for circulation and tissue perfusion.
d. Insert a urinary catheter and assess for hematuria. Correct
Answers c. Check for circulation and tissue perfusion.
Rationale:The initial assessment is focused on determining
whether the patient has hypovolemic shock. The knife should
not be removed until the patient is in surgery, where bleeding
can be controlled. Rovsing sign is assessed in the patient with
suspected appendicitis. Assessment for bladder trauma is not
part of the initial assessment.
,A 19-yr-old women admitted with anorexia nervosa is 5 ft, 6 in
(163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal
hypokalemia and iron deficiency anemia. Which patient problem
has the highest priority?
A.Difficult coping
B.Disturbed body image
C.Impaired nurtitional status
D.Risk for electrolyte imbalance Correct Answers Risk for
electrolyte imbalance
Rationale:The patients hypokalemia may lead to life-threatening
cardiac dyshythmias. The other diagnosis are also appropriate
for this patient but are not associated with amidiate risk for fatal
complications.
A 20-yr-old women is being admitted with electrolyte disorders
of unknown etiology. Which assessment finding is most
important to report to the health care provider?
A. The patient uses laxitives daily
B.The patients knuckles are macerated
C.The patients serum potassium level is 2.9 mEq/L
D.The patient has a history of extreme weight Correct Answers
The patients serum potassium level is 2.9 mEq/L
Rationale: The low serum potassium level may cause life-
threatening cardiac dysrhthmias, and potassium supplementation
is needed rapidly
A 22-yr-old female patient with an exacerbation of ulcerative
colitis is having 15 to 20 stools daily and has excoriated perianal
skin. Which patient behavior indicates that teaching regarding
maintenance of skin integrity has been effective?
,a. The patient uses incontinence briefs to contain loose stools.
b. The patient uses witch hazel compresses to soothe irritation.
c. The patient asks for antidiarrheal medication after each stool.
d. The patient cleans the perianal area with soap after each stool.
Correct Answers b. The patient uses witch hazel compresses to
soothe irritation.Witch hazel compresses are suggested to reduce
anal irritation and discomfort.
A 25-yr-old male patient calls the clinic reporting diarrhea for
24 hours. Which action should the nurse take first?
a. Inform the patient that testing of blood and stools will be
needed.
b. Suggest that the patient drink clear liquid fluids with
electrolytes.
c. Ask the patient to describe the stools and any associated
symptoms.
d. Advise the patient to use over-the-counter antidiarrheal
medication. Correct Answers . Ask the patient to describe the
stools and any associated symptoms.
Rationale:The initial response by the nurse should be further
assessment of the patient. The other responses may be
appropriate, depending on what is learned in the assessment.
A 26-yr-old women is being evaluated for vomiting and
abdominal pain.Whuch question from the nurse will be most
useful in determining the cause of the patients symptoms?
A."What type of foods do you eat?"
B."Is it possible that you are pregnant?"
C."Can you tell me more about the pain?"
D."What is your usual elimination pattern?" Correct Answers
"Can you tell me more about the pain?"
, Rationale:A complete description of the pain provides cles about
the cause of the problem.
A 33-yr-old male patient with a gunshot wound to the abdomen
undergoes surgery, and a colostomy is formed as shown in the
accompanying figure. Which information will be included in
patient teaching?
a. Stool will be expelled from both stomas.
b. This type of colostomy is usually temporary.
c. Soft, formed stool can be expected as drainage.
d. Irrigations can regulate drainage from the stomas. Correct
Answers b. This type of colostomy is usually temporary.
Rationale:A loop, or double-barrel stoma, is usually temporary.
Stool will be expelled from the proximal stoma only. The stool
from the transverse colon will be liquid and regulation through
irrigations will not be possible.
A 40-yr-old male patient has had a herniorrhaphy to repair an
incarcerated inguinal hernia. Which patient teaching will the
nurse provide before discharge?
a. Soak in Sitz baths several times each day.
b. Cough 5 times each hour for the next 48 hours.
c. Avoid using acetaminophen (Tylenol) for pain.
d. Apply a scrotal support and ice to reduce swelling. Correct
Answers d. Apply a scrotal support and ice to reduce swelling.
Rationale:A scrotal support and ice are used to reduce edema
and pain. Coughing will increase pressure on the incision. Sitz
baths will not relieve pain and would not be of use after this
surgery. Acetaminophen can be used for postoperative pain.
