Test Bank for MBAA 604 Chapter 57: Care of Patients with Inflammatory Intestinal Disorders Ignatavicius: Medical-Surgical Nursing, 8th Edition

1. A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion 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 gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion. DIF: Remembering/Knowledge REF: 1169 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse cares for an older adult client who has Salmonella food poisoning. The client’s vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination. ANS: B Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, 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. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| hydration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client’s teaching? a. “Drink plenty of fluids to prevent dehydration.” b. “You should only drink 1 liter of fluids daily.” c. “Increase your protein intake by drinking more milk.” d. “Sips of cola or tea may help to relieve your nausea.” ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort