BIOLOGY 102. Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition CHAPTER 23

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER 23

Chapter 23

1. The client has been diagnosed with type 1 herpes simplex lesions on the mouth and face. Which of the following statements indicates the client’s understanding of the information the nurse has discussed with him?

1. “I will have this condition for life.”

2. “This has been caused by a bacterial infection.”

3. “I have come into contact with some type of fungal infection.”

4. “An antibiotic will help heal these sores in about three days.”

2. Acyclovir ointment has been prescribed for oral herpes lesions. The client has questions about the use of the medication. Which of the following should be included in the information provided to the client?

1. Acyclovir is an antibiotic medication.

2. Acyclovir can reduce the length of the herpes outbreak.

3. Acyclovir will cure the disorder.

4. Acyclovir acts as an anti-inflammatory agent.

3. A client presents to the ambulatory clinic with manifestations consistent with an oral fungal infection. The client’s health history is unremarkable. Which of the following does the nurse anticipate initially being ordered to manage this condition?

1. Ampicillin

2. Nystatin

3. Anbesol

4. Fluconazole

4. An elderly client presents with a significant weight loss. The assessment reveals poorly fitting dentures, which have caused severe oral sores. When preparing the plan of care, which of the following interventions will be most beneficial to the client?

1. Provide analgesics as needed.

2. Determine the need for assistive devices.

3. Serve meals in an attractive environment.

4. Offer assistance to eat.

5. A client diagnosed with oral cancer has undergone surgery to manage the condition. The nurse is developing the plan of care. Which of the nursing diagnoses identified has the highest priority?

1. Body Image, Disturbed

2. Communication: Impaired, Verbal

3. Nutrition, Imbalanced: More than Body Requirements, Risk for

4. Airway Clearance, Ineffective

6. The client has been diagnosed with gastroesophageal reflux (GERD) . The nurse is providing instructions to assist with managing the condition. What information should be included in the teaching \?

1. Limit oral intake half an hour before bedtime.

2. Sit upright for one hour after eating

3. Elevate the head of the bed on 6–8-inch blocks.

4. Take medications with tomato juice.

7. A client taking an antacid reports experiencing muscle cramping. The client asks the nurse what could be causing the discomfort. What actions are indicated?

1. The nurse should notify the physician.

2. The nurse should review the client’s diet history.

3. The nurse should review the client elimination patterns.

4. The nurse should provide reassurance to the client.

8. A client who has been experiencing nausea voices an interest in aromatherapy to manage the condition. What response by the nurse will be most therapeutic?

1. “Aromatherapy has shown very limited effectiveness with nausea.”

2. “Aromatherapy allows the client to exert conscious control over physiologic processes.“

3. “Why are you considering this method?”

4. “Ginger has been used with some success to manage nausea.”

9. A client is hospitalized with gastrointestinal bleeding. The nurse completes the shift assessment. Which findings indicate the client’s condition is worsening?

1. Urinary output has increased 50 mL more than the previous hour.

2. Skin is warm, and dry. Cool and warm contradict each other, so I eliminated one.

3. The client reports feeling very tired.

4. Increased capillary refill time.

10. During a follow-up visit four weeks after gastric bypass surgery, a client reports experiencing cramping, nausea, and diarrhea within 10 minutes after eating. What information should be given to the client?

1. “This is a normal occurrence, and will subside in a few months.”

2. “Try to eat slower.”

3. “Smaller, frequent meals might reduce the incidence of this phenomenon.”

4. “Try drinking a small amount of fluid prior to eating.”

11. Discharge teaching for the client with peptic ulcer disease is being planned. Which of the following should be included in the information provided to the client?

1. Eat a small snack before bedtime.

2. Follow a bland diet.

3. Avoid ingestion of any alcohol.

4. Discontinue cigarette use.

12. The nurse is providing emotional support to the spouse of a client recently diagnosed with terminal esophageal cancer. The spouse voices feelings of anger and confusion. The spouse questions why his partner did not seek help sooner. What response by the nurse is indicated at this time?

1. “Unfortunately, the early symptoms are often vague, and often not recognized as something serious.”

2. “Your spouse was probably afraid of getting bad news.”

3. “You will never know.”

4. “It is not important to know that right now.”

13. The client has reported to the clinic with complaints of heartburn, reflux, and belching. Which of the following diagnostic tests do you anticipate being utilized to further investigate the client’s concerns?

1. Upper GI series

2. Colonoscopy change to EKG

3. Barium enema

4. Chest x-ray

The above changes would make it an Analysis question rather than an easy application.

14. The client has presented with complaints of mouth soreness. A review of the client’s medical health history reveals gastric bypass surgery one year ago. During the assessment, the nurse notes the client’s tongue is beefy, red, and smooth. Based upon your knowledge, what do you anticipate will be included in the diagnostic workup ordered for the client?

1. Vitamin B_{12 l}evels

2. Iron levels

3. Vitamin B₆ levels

4. Potassium levels

15. While providing care for a client who had gastric surgery five days ago, the color of the gastric fluid is noted as red. The client’s vital signs are temperature 98°F; heart rate 104; respirations 23; blood pressure 105/69. What action by the nurse is indicated?

1. Document the findings and notify the physician.

2. Document the findings and reassess the client in four hours.

3. Review the client’s most recent laboratory results.

4. Document the findings and review the nasogastric suction settings.