Deck 10: Inflammation

Question 1

The nurse is caring for an older adult client with gallbladder disease recovering from a cholecystectomy.Which risk factors increase this client's susceptibility to infection? Select all that apply.

A) Dry skin
B) Advanced age
C) Intact mucous membranes
D) Non-intact skin
E) Active bowel sounds

Answer 1

Advanced age
Non-intact skin

Question 2

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy.During the assessment,the nurse is unable to hear any bowel sounds.The client denies passing flatus.Which action is most appropriate by the nurse?

A) Withholding food and fluid intake until intestinal motility has returned
B) Encouraging the client to increase fluid intake to promote peristalsis
C) Encouraging the client to increase solid food intake to promote peristalsis
D) Encouraging the client to decrease the amount of oral intake

Answer 2

Withholding food and fluid intake until intestinal motility has returned

Question 3

The nurse is caring for a client from India who has extensive deep tissue damage.The nurse notes that the client is also vegan.Which dietary information should the nurse teach this client to enhance the healing process?

A) "A low-fat, high-carbohydrate, low-protein diet is best for healing."
B) "A high-fat, low-carbohydrate diet is best for healing."
C) "A high-carbohydrate, high-protein diet is best for healing."
D) "A diet high in protein and vitamin D is best for healing."

Answer 3

"A high-carbohydrate, high-protein diet is best for healing."

Question 4

A client is admitted with airway edema,bronchoconstriction,and increased mucus production after being exposed to an allergen.Which nursing interventions are appropriate to address this inflammation to the respiratory system? Select all that apply.

A) Turn and reposition every 2 hours.
B) Monitor oxygen saturation.
C) Administer oxygen as prescribed.
D) Restrict fluids.
E) Monitor lung sounds.

Question 5

The nurse in a rheumatology clinic is managing care for clients who receive nonsteroidal anti-inflammatory drugs (NSAIDs)for the treatment of their disease processes.Which are the primary laboratory tests the nurse will assess prior to initiation of this type of therapy? Select all that apply.

A) Serum amylase
B) Electrolytes
C) Creatine clearance
D) Complete blood count (CBC)
E) Liver function tests

Question 6

The nurse instructs an older adult client with arthritis on the side effects of nonsteroidal anti-inflammatory drug (NSAID)therapy.Which client statement would indicate that teaching had been effective?

A) "I will report any abnormal bruising."
B) "Caffeine will decrease the effectiveness of the medication."
C) "I cannot take other medications."
D) "If I have a change in my mood I will call the prescriber."

Question 7

The nurse is providing instructions to a client who is prescribed a nonsteroidal anti-inflammatory drug (NSAID).Which information is priority for the nurse to explain to the client about this medication?

A) "Take your medication on an empty stomach."
B) "Drink at least 8-10 glasses of water a day while taking your medication."
C) "Constipation is common with your medication; include roughage in your diet."
D) "Take your medication with food."

Question 8

The adult female Iranian client develops signs and symptoms of appendicitis during the night.The client is brought to the emergency department by family.Which nursing intervention is the most culturally sensitive for this client?

A) Ask the healthcare provider which one should see the client.
B) Ask for a female healthcare provider to assess the client.
C) Ask for a male healthcare provider to assess the client.
D) Explain the assessment procedure and ask the family their preference.

Question 9

The nurse is caring for a client in the emergency department who is suspected of having appendicitis.Based on this data,which prescriptions does the nurse anticipate from the healthcare provider? Select all that apply.

A) A cephalosporin
B) A barium enema
C) Regular diet
D) Pain medication
E) Complete white blood cell count

Question 10

The nurse is caring for a pediatric client recovering from surgery for a perforated appendix.Which nursing diagnosis should the nurse use to guide this client's care during the immediate postoperative period?

A) Risk for Chronic Pain
B) Risk for Impaired Perfusion
C) Risk for Deficient Fluid Volume
D) Risk for Infection

Question 11

The nurse is caring for a client who was admitted to the hospital 1 day prior with cholelithiasis.Which new assessment finding indicates the stone has probably obstructed the common bile duct?

A) Nausea and vomiting
B) Jaundice
C) Right upper quadrant (RUQ) pain
D) Elevated cholesterol level

Question 12

A client with appendicitis is highly agitated and states that there is a great deal of pain.Which intervention will decrease the client's anxiety?

A) Assess pain levels every 2 hours and administer ordered medication.
B) Provide reading material to help distract the client.
C) Distract the client with ambulation.
D) Administer pain medications when the client complains of pain.

Question 13

A client is admitted to the hospital with an elevated temperature,nausea,and pain and tenderness in the lower right quadrant of the abdomen.After receiving pain medication,the client continues to complain of pain at a level of 8 on a 1-10 pain scale.Pain medications are not due for at least another 2 hours.Which statement by the nurse is appropriate?

A) "I will inform the healthcare provider about your continued pain."
B) "I do not have any medications ordered for you at this time."
C) "Try to rest for a while longer until it is time to receive your medication"
D) "Let's try a heating pad or warm blanket to see if that helps with your discomfort."

Question 14

The nurse,caring for older school-age client recovering from an appendectomy,is preparing to help the family ambulate the child for the first time after surgery.Which non-pharmacological nursing strategy would be appropriate for this client?

A) A warm, moist pack over the site of the incision
B) A splint pillow against the abdomen when moving or coughing
C) Administering appropriate narcotic analgesics
D) An ice pack over the site of the incision

Question 15

The nurse is caring for a client with severe inflammation.Which assessment findings would indicate a systemic reaction to inflammation? Select all that apply.

A) Erythema
B) Edema
C) Pain
D) Tachypnea
E) Tachycardia

Question 16

The nurse is caring for a client who has experienced a sports-related injury to the knee.During the morning assessment,which signs of inflammation does the nurse anticipate? Select all that apply.

A) Pitting edema
B) Pallor
C) Swelling
D) Warmth
E) Pain

Question 17

The nurse is providing care to a client who experiences chronic inflammation due to arthritis.Which collaborative intervention does the nurse plan for when providing care to this client?

A) Administering anti-inflammatory medications
B) Administering diuretics
C) Administering frequent doses of opioid medications
D) Administering antibiotics

Question 18

A client with acute abdominal pain is scheduled for an appendectomy in 3 hours.While waiting for the surgery,the client reports that the pain has subsided.Which is the priority action by the nurse?

A) Determine when the client can be medicated for pain.
B) Contact the surgery department.
C) Contact the healthcare provider.
D) Notify the nursing supervisor.

Question 19

List the pathophysiology processes involved in appendicitis in sequential order.

A) The appendix becomes distended with fluid secreted by its mucosa.
B) Obstruction of the proximal lumen of the appendix is apparent.
C) Purulent exudate formed causes further distention of the appendix.
D) Pressure within the lumen of the appendix increases.
E) Tissue necrosis and gangrene result.

Question 20

A nurse checking for tenderness at McBurney's point for a client with suspected appendicitis will palpate which area?

A) A
B) B
C) C
D) D

Question 21

The nurse is caring for an African-American client with nephritis.For which long-term complication should the nurse include interventions to prevent when planning this client's care?

A) Congestive heart failure
B) Diabetes mellitus
C) End-stage renal disease
D) Hypertension

Question 22

A nurse caring for a pediatric client with inflammatory bowel disease (IBD)understands that there are variances in the presentation of IBD between children and adults.Which variances does the nurse anticipate for this pediatric client? Select all that apply.

A) Children suffer from Crohn disease more frequently than ulcerative colitis
B) Pediatric clients often present with fistulizing or stricturing disease.
C) Pediatric clients usually have colonic involvement.
D) Pediatric clients more often present with left-sided colitis.
E) IBD is more common in females than males in the pediatric population

Question 23

A client is being scheduled for diagnostic tests to determine the presence of ulcerative colitis.For which diagnostic tests should the nurse plan to provide teaching? Select all that apply.

A) Barium enema
B) Intravenous pyelogram
C) Colonoscopy
D) Upper endoscopy
E) Barium swallow

Question 24

The nurse is caring for an adolescent client who has been non-adherent with the medical plan of care to treat Crohn disease.In order to increase adherent behavior,which complication associated with Crohn disease will the nurse include in the client's teaching plan?

A) Vomiting
B) Bowel perforation
C) Intestinal obstruction
D) Diarrhea

Question 25

A client who is 4 days post-cholecystectomy has T-tube drainage totaling 600 mL in 24 hours.Which actions by the nurse are appropriate based on this data? Select all that apply.

A) Notify the healthcare provider.
B) Place the client in a supine position.
C) Assess drainage characteristics.
D) Clamp the tube q 2 hours for 30 minutes.
E) Encourage an increased fluid intake.

Question 26

A nurse is receiving a client from the emergency department diagnosed with an acute exacerbation of ulcerative colitis (UC).The nurse anticipates the client may present with which clinical characteristics? Select all that apply.

A) 5-30 diarrhea stools per day with blood and mucus
B) Steady right lower quadrant or periumbilical pain
C) Cramping in left lower quadrant; relieved by defecation
D) Tenderness and mass noted in right lower quadrant
E) Fever, malaise, fatigue

Question 27

The nurse is evaluating care provided to an older adult client with a history of cholecystitis 5 months ago.Which statement indicates the client met a goal in the plan of care?

A) "I have increased my intake of fat."
B) "I have been eating out often."
C) "I have been walking 1 mile every day."
D) "I have been able to gain 5 pounds on the new diet."

Question 28

The nurse conducts an evaluation after completing a training session for community members on ways to prevent nephritis.When evaluating the success of this session,what responses should the members provide as evidence that learning has been successful? Select all that apply.

A) Practicing good hygiene
B) Not smoking
C) Maintaining a healthy body weight
D) Limiting alcohol intake
E) Controlling high blood pressure

Question 29

A nurse is caring for a client with severe acute abdominal pain secondary to cholelithiasis.Which nursing actions promote effective pain management? Select all that apply.

A) Withhold oral food and fluids.
B) Insert nasogastric tube and connect to high wall suction.
C) Educate the client about decreasing protein in the diet, as protein increases gallbladder contractions.
D) Administer morphine, meperidine, or another opioid analgesic as ordered.
E) Place the patient in supine position to relieve abdominal pain.

Question 30

An adolescent client with complications related to ulcerative colitis is scheduled for an ileostomy.The client is concerned about the social effects of this surgery and asks the nurse what to expect related to bowel function and care after surgery.Which responses from the nurse to the client are appropriate? Select all that apply.

A) "The stoma will require that you wear a collection device all the time."
B) "The drainage tends to be liquid but certain foods can cause it to be paste-like."
C) "The drainage will gradually become semi-solid and formed."
D) "After the stoma heals, you can irrigate your bowel so you won't have to wear a pouch."
E) "You will be able to have some control over your bowel movements."

Question 31

The nurse educator in a gastrostomy clinic is teaching a group of clients about how nutrition plays a role in the formation of gallstones.Which client would the nurse expect to benefit the most from this teaching session?

A) The Native American client
B) The African-American client
C) The Asian client
D) The Norwegian client

Question 32

A home health nurse is evaluating a client who had a colostomy placed 6 weeks ago for the treatment of ulcerative colitis.Which assessment will cause the nurse to conclude that teaching goals for this client have been met?

A) A colostomy pouch that is clean and dry
B) Vital signs that reveal a normal temperature
C) A stoma that is pink and intact
D) The client experiences pain with certain types of food.

Question 33

The nurse is caring for a client newly admitted to the hospital with uncomplicated cholelithiasis.Based on this data,which laboratory value does the nurse anticipate to be elevated?

A) Mean corpuscular hemoglobin concentration (MCHC)
B) Indirect bilirubin
C) Serum amylase
D) Alkaline phosphatase

Question 34

The nurse has identified the diagnosis Excess Fluid Volume as appropriate for a client with acute glomerulonephritis.What should the nurse assess to learn the most accurate indication of this client's fluid balance?

A) Vital signs
B) Intake and output records
C) Daily weight
D) Serum sodium levels

Question 35

An adolescent client is experiencing abdominal pain with diarrhea and bloody stools.Based on this data,which specific type of inflammatory bowel disease does the nurse suspect the client is experiencing?

A) Appendicitis
B) Ulcerative colitis
C) Crohn's disease
D) Necrotizing enterocolitis

Question 36

The nurse is teaching the family of a school-age client diagnosed with inflammatory bowel disease on the administration of prednisone at home.At which time should the nurse instruct the parents to provide the medication to the client?

A) 1 hour before meals
B) At bedtime
C) With meals
D) Between meals

Question 37

The nurse is caring for a client newly admitted to the medical-surgical unit with glomerulonephritis.Which classic manifestations of this disorder should the nurse expect to assess in this client? Select all that apply.

A) Edema
B) Weight loss
C) Hematuria
D) Acute flank pain
E) Proteinuria

Question 38

The nurse is caring for an older adult client with cholecystitis.The client has been admitted to the hospital for diagnostic testing and pain control.Which nursing diagnosis would be a priority for this client?

A) Anxiety
B) Risk for Infection
C) Impaired Comfort
D) Imbalanced Nutrition: Less than Body Requirements

Question 39

A client with cholelithiasis is in the clinic for a follow-up assessment following hospitalization.What lifestyle modification should the nurse teach the client to decrease the pain associated with the disease process?

A) Reduce sodium intake
B) Decrease fat consumption
C) Increase fluids
D) Decrease smoking

Question 40

The nurse provides teaching on the diagnosis Risk for Deficient Fluid Volume to a client with ulcerative colitis.Which client statement indicates understanding of this information?

A) "I will drink 1 liter of fluid each day."
B) "I will continue to use a moisturizer on my skin."
C) "I should report dry patches of skin immediately to my doctor."
D) "If I have two liquid stools in any day, I will report this to my health care provider."

Question 41

A child who is hospitalized with acute glomerulonephritis experiences blurred vision and headache while in the playroom.Which action by the nurse is the most appropriate?

A) Reassure the child and encourage bed rest until the headache improves.
B) Obtain the child's blood pressure and notify the physician.
C) Check the urine to see if hematuria has increased.
D) Obtain serum electrolytes and send a urinalysis to the lab.

Question 42

A client is experiencing weight gain and foamy dark urine 4 weeks after being treated with antibiotics for a sore throat.Which client statement,made during the health history assessment,should the nurse provide further instruction?

A) "I have been trying to get plenty of rest since I have been sick."
B) "I have changed to a more nutritious diet."
C) "I felt better after 1 week of the antibiotics, so I stopped taking them."
D) "I have gained weight in the last 2 weeks."

Question 43

The nurse is planning a teaching session regarding peptic ulcers for the residents of an assisted-living complex.Which concepts about peptic ulcer disease should the nurse include in the presentation to the residents? Select all that apply.

A) A colonoscopy is the most common test used to diagnose the presence of a gastric ulcer.
B) Gastric ulcers are more common than duodenal ulcers.
C) Many peptic ulcers are infected with H. pylori and are treated with antibiotics.
D) The first sign of a peptic ulcer may be serious gastrointestinal bleeding.
E) The individual with a peptic ulcer will most likely experience pain after eating.

Question 44

A nurse caring for a client with a gastric ulcer understands that which are the two most likely locations of this ulcer to develop?
Select all that apply.

A) Lesser curvature
B) Greater curvature
C) Distal to the pylorus
D) Proximal to the pylorus

Question 45

The nurse is planning a teaching session for older community members about the risks for peptic ulcer disease (PUD)found with this age group.What should the nurse include when teaching this community group?

A) PUD in an older client causes less bleeding than in a younger client.
B) The elderly client experiences more severe abdominal pain than a younger client with PUD.
C) Older clients should undergo colonoscopy when diagnosed with PUD.
D) Peptic ulcer disease (PUD) is likely to be exacerbated by the bacterium H. pylori.

Question 46

A client being discharged after treatment for nephritis is concerned about having adequate stamina to care for the children after discharge.Which statement made by the nurse would be most appropriate to address the client's concern?

A) "Tell your spouse he has to help you."
B) "You will be able to keep up with your family's needs once you return home."
C) It sounds like you need some help, so I'll contact Social Services for support."
D) "Maybe your children should go and stay with a relative or neighbor for a few weeks."

Question 47

The healthcare provider prescribes misoprostol (Cytotec)for a female client for the treatment of peptic ulcer disease.What should the nurse ask the client prior to administration of this medication?

A) "Is there any chance that you are pregnant?"
B) "Are you currently sexually active?"
C) "Are your menstrual cycles irregular?"
D) "Do you plan on becoming pregnant in the next few months?"

Question 48

A client being treated for nephritic syndrome is a vegetarian and has a poor oral intake.Which action should the nurse take to meet this client's nutritional needs?

A) Request that the healthcare provider prescribe an appetite stimulant.
B) Request a dietician to discuss the client's dietary preferences.
C) Encourage the client to eat the food provided on the meal trays.
D) Explain that the client will be returning home soon and can resume a preferred diet.

Question 49

A nurse is educating a client with peptic ulcer disease (PUD)regarding Helicobacter pylori and its role in PUD.Which statements by the nurse are appropriate to include in the teaching session? Select all that apply.

A) "The bacteria produces enzymes that improves the efficacy of mucous gel in protecting the gastric mucosa."
B) "Helicobacter pylori infection is found in about 25% of individuals with PUD."
C) "Your inflammatory response to H. pylori contributes to gastric cell damage."
D) "H. pylori infection increases production of gastric acids."
E) "H. pylori infection is spread by droplets in the air."

Question 50

The nurse is teaching a client with a peptic ulcer on appropriate lifestyle alterations.The family voices questions as to why some of the recommendations have been made.Which explanation should be offered by the nurse?

A) "Alcohol acts to suppress gastric immunity and should be avoided."
B) "Caffeine intake is often associated with an increase in abdominal pain."
C) "Cigarette smoking doubles the risk of developing peptic ulcer disease and should be avoided."
D) "Alcohol stimulates gastric acid secretion, which can cause further irritation."

Question 51

The nurse is caring for a client who receives H2-receptor antagonists for the treatment of peptic ulcer disease.Based on the nursing diagnosis Risk for Bleeding,which assessment finding should the nurse report immediately to the healthcare provider?

A) The client who reports pain after 24 hours of treatment
B) The client who reports episodes of melena
C) The client who reports he is constipated
D) The client who reports he took TUMS antacids with his H2-receptor antagonist

Question 52

A client is being treated with blood transfusions for a large peptic ulcer in the duodenum.Which information in the client's history should the nurse suspect as causing this health problem?

A) Allergies to penicillin and morphine sulfate
B) History of chronic atrial fibrillation
C) Daily medications include naproxen sodium and warfarin (Coumadin).
D) Six weeks postoperative cataract extraction with lens implant

Question 53

The nurse provides discharge teaching for a client with peptic ulcer disease (PUD).Which client statement indicates that teaching has been effective?

A) "I will drink more milk and limit spicy foods."
B) "I will take ibuprofen (Motrin) for my headaches."
C) "I will limit my intake of coffee."
D) "I will join a gym and increase my exercise."

Question 54

A client with H.pylori asks the nurse why bismuth (Pepto-Bismol)has been prescribed along with oral antibiotics for treatment.What should the nurse explain about the use of bismuth (Pepto-Bismol)for treatment of this health problem? Select all that apply.

A) "It helps prevent the side effects of antibiotics."
B) "It increases stomach acid to help kill bacteria."
C) "It helps relieve ulcer-related constipation."
D) "It is effective with inhibiting bacterial growth."
E) "It keeps bacteria from sticking in your stomach."