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Chapter 56: Assessment of the Gastrointestinal System

MULTIPLE CHOICE

1. Parasympathetic stimulation of the gastrointestinal tract


A. Increases motor and secretory activity and relaxation of sphincters.
B. Maintains the tone of smooth muscles to stimulate movement.
C. Slows movement, inhibits secretion and contracts sphincters.
D. Decreases blood supplied to the gastrointestinal tract.

ANS: A
Parasympathetic stimulation of the GI tract is provided by the vagus nerve causing increases in motor and
secretory activity and relaxation of sphincters.

2. Which problem should the nurse anticipate in the client undergoing radiation for cancer
of the oral cavity?
A. The client will fail to absorb most nutrients.
B. The client will be able to digest carbohydrates but not proteins.
C. The client will have an impairment in the softening and breaking down of food.
D. The client will have difficulty propelling food from the mouth to the esophagus.

ANS: C
Saliva is responsible for the softening of food in the mouth and contains an enzyme (ptyalin) that assists in
the breakdown of carbohydrates.

3. A client with damage to cranial nerve X describes difficulty in moving food toward the
rear of the mouth for swallowing. With which phase of swallowing is this client experiencing difficulty?
A. Esophageal
B. Pharyngeal
C. Propulsant
D. Voluntary

ANS: D
The movement of the tongue forcing food towards the pharynx is called the voluntary phase of swallowing.
Paralysis of cranial nerve X would impede this function.

4. What alteration in function can be expected if parietal cells of the stomach become
impaired?
A. Gastric motility will be decreased.
B. Secretion of gastrin will be increased.
C. Secretion of pepsinogen will be increased.
D. Absorption of vitamin B12 will be decreased.

ANS: D
Parietal cells of the stomach secrete hydrochloric acid and produce intrinsic factor, which aids in the
absorption of vitamin B12.

5. A client has developed diabetes mellitus type 1 and no longer produces insulin. What
cells of the pancreas have become dysfunctional?
A. Beta cells
B. Alpha cells
C. Acinar cells
D. Kupffer cells

ANS: A
The endocrine part of the pancreas is composed of the islets of Langerhans, with alpha cells producing
glucagon and beta cells producing insulin.

6. What is the role of the liver in response to increased energy requirements?


A. Storage of fatty acids and triglycerides
B. Activation of Kupffer cells
C. Storage and release of glycogen
D. Removal of ammonia

ANS: C
The liver’s role in carbohydrate metabolism involves the storage and release of glycogen as energy
requirements change. An increase in energy requirements results in the release of glycogen.

7. What statement regarding changes to the gastric mucosa in an older adult is true?
A. Peristalsis decreases and nerve impulses are dulled.
B. Atrophy of gastric mucosa results in hypochlorhydria.
C. Lipase production is decreased.
D. Protein synthesis is decreased.

ANS: B
In older adults, the gastric mucosa atrophies. There is a decrease in the number of gastrin-secreting cells,
which leads to hypochlorhydria.

8. Which of the following questions would be appropriate to ask the client in order to
collect data concerning the Nutritional-Metabolic Pattern, according to Gordon’s Functional Health
Patterns?
A. “Have you noticed a change in the amount of urine passed?”
B. “Have you experienced any recent changes in weight?”
C. “What is your usual bowel elimination pattern?”
D. “When was your last rectal examination?”

ANS: B
Data about changes in weight, food intake, and difficulties chewing or swallowing are reflective of the
Nutritional-Metabolic Pattern. All other choices reflect questions posed to collect data concerning the
Elimination Pattern.

9. What question should the nurse ask to obtain information as to the origin of acute
diarrhea times 4 days?
A. “Have you traveled out of the country recently?”
B. “Are you taking any anti-inflammatory drugs?”
C. “Have you had a colonoscopy recently?”
D. “Do you have trouble swallowing?”

ANS: A
A history of travel may help pinpoint an infectious source of symptoms such as diarrhea.

10. During an initial assessment, a client with gastrointestinal problems reports the use of
nonsteroidal anti-inflammatory drugs (NSAIDs) three times a day for arthritis pain. What would be the
nurse’s best response?
A. “NSAIDs are not helpful for arthritis pain.”
B. “NSAIDs should be taken only twice daily.”
C. “NSAIDs can interfere with the absorption of nutrients.”
D. “NSAIDs can result in ulcers or bleeding.”

ANS: D
Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through the inhibition of
prostaglandins.

11. Which of the following clients is most at risk of developing colon cancer?
A. 54-year-old white female client with irritable bowel syndrome
B. 60-year-old African American male who smokes occasionally
C. 42-year-old Asian male who travels and eats out frequently
D. 22-year-old female taking oral contraceptives

ANS: B
Colon cancer is more prevalent among African American men.

12. While examining the oral cavity of a client, the nurse detects a fruity odor to the client’s
breath. The nurse should do which of the following?
A. Instruct the client to use mouthwash after all meals.
B. Instruct the client in good oral hygiene.
C. Document the finding as the only action.
D. Notify the physician.

ANS: D
A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The nurse should
notify the physician or health care provider so that the appropriate steps to investigate this finding can be
taken.

13. The nurse is preparing to perform an abdominal assessment on a client with a complaint
of right upper quadrant tenderness. In what sequence should palpation be performed?
A. Lower quadrants only
B. Right upper quadrant first
C. Right upper quadrant last
D. Lower quadrants and left upper quadrant only

ANS: C
The sequence of palpation should be to palpate any tender or painful areas last to prevent the client from
tensing abdominal muscles because of pain, thereby making the examination more difficult.

14. On inspection of the abdominal contour of a client with upper left quadrant pain, the
nurse notes that the left abdominal contour appears asymmetric. What conclusion should the nurse draw
from this finding?
A. Left upper quadrant asymmetry is a normal finding.
B. Left upper quadrant asymmetry can be caused by pregnancy.
C. Left upper quadrant asymmetry can be indicative of a tumor or cyst.
D. Left upper quadrant asymmetry is indicative of peristaltic movements.

ANS: C
Left upper quadrant asymmetry can be indicative of a tumor or pancreatic cyst.

15. While auscultating the abdomen of a client, the nurse notes increased, loud, gurgling
bowel sounds. What would be the nurse’s best action?
A. Palpate the abdomen.
B. Percuss the abdomen.
C. Notify the physician.
D. Document the finding as the only action.

ANS: C
The presence of increased, loud, gurgling bowel sounds is associated with hypermotility, which can be
associated with diarrhea or gastroenteritis. This sound also is heard above a complete intestinal obstruction,
and the physician should be notified because the client requires measures to relieve the obstruction, if
present.

16. Which technique should the nurse use to measure the liver span of a client admitted with
cirrhosis?
A. Auscultation
B. Percussion
C. Inspection
D. Palpation

ANS: B
Although the liver edge can be felt on palpation, percussion is used to determine the span of the liver and
other solid organs. The nurse percusses down the midclavicular line below the right nipple until resonance
changes to dullness. The nurse marks this area as the upper border of the liver. The nurse then percusses up
from the iliac crest in the midclavicular line until the percussion notes change from tympany to dullness,
indicating the lower border of the liver. The nurse marks this area and measures the distance between the
two marks (the liver span), which is normally 5 to 10 cm.

17. The nurse is performing an abdominal assessment of a client and, during percussion,
notes the presence of dullness forward of the tenth intercostal space at the left midaxillary line. What
conclusion can the nurse draw from this finding?
A. The client has splenomegaly.
B. The client’s spleen is of normal size.
C. The client’s spleen and pancreas are enlarged.
D. The client’s spleen is obstructed by an enlarged heart.
ANS: A
The spleen is located at the tenth intercostal space in the left midaxillary line. If dullness is heard forward
of the midaxillary line or in the left anterior axillary line, this is indicative of splenomegaly.

18. While performing an examination for rebound tenderness on a client with upper right
quadrant abdominal pain, the nurse notes a positive Blumberg’s sign. What action should the nurse take?
A. Document this normal finding.
B. Report this finding to the health care provider.
C. Immediately follow with auscultation to detect bowel obstruction.
D. Repeat the maneuver with the client in a supine position with the knees flexed.

ANS: B
A positive Blumberg’s sign is indicative of rebound tenderness and should be reported to the health care
provider.

19. In a client admitted with cirrhosis of the liver, which serum levels would the nurse expect
to be elevated?
A. Serum amylase and lipase
B. Serum ammonia
C. Serum calcium
D. Serum CEA

ANS: B
Serum ammonia levels are elevated in conditions that incur hepatocellular injury, such as cirrhosis of the
liver. Increased serum amylase and lipase levels are indicators of pancreatitis. CEA levels are useful in
assessing the success of cancer therapy or the recurrence of cancer.

20. On assessment of the abdomen of a client 24 hours post–barium swallow, the nurse notes
decreased bowel sounds. The client reports having had no bowel movement for 2 days. What conclusion
can be drawn from these findings?
A. This is a normal finding following a barium swallow.
B. These findings may indicate a barium impaction.
C. The client requires an order for milk of magnesia.
D. The client’s diet may need advancement to stimulate peristalsis.

ANS: B
Clinical manifestations such as decreased or absent bowel sounds, constipation, or obstipation after barium
swallow are indicative of barium impaction and could lead to obstruction. These symptoms should be
reported to the physician immediately.

21. What client instructions would be appropriate after a barium swallow?


A. “Sit in bed with your head elevated to allow the barium to pass through.”
B. “You may have stools that are darker in appearance for a few days.”
C. “You may not eat or drink anything for 6 hours after the test.”
D. “Drink plenty of fluids.”
ANS: D
The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from
the colon.

22. Which statement made by the client indicates a need for further teaching regarding the
client’s preparation for a barium enema?
A. “I will take nothing by mouth after midnight on the day of the examination.”
B. “I will be given a laxative to take the evening before the examination.”
C. “I will be asked to retain the barium during the examination.”
D. “I will eat soft foods only for 12 to 24 hours before the examination.”

ANS: D
The client is instructed to take only clear liquids 12 to 24 hours before the examination to reduce the
amount of fecal material in the bowel.

23. A client has just returned to the unit after having a percutaneous transhepatic
cholangiography. Which of the following should be included in the plan of care?
A. The client can be discharged after voiding.
B. The client should be kept NPO for 6 hours postprocedure.
C. Position the client on the right side with a sandbag against the lower ribs.
D. The client should ambulate with assistance only for the first 2 hours postprocedure.

ANS: C
The client should be positioned on the right side with a sandbag against the lower ribs to prevent bleeding.
The nurse assesses the client’s vital signs and the lower right rib cage area for signs of bleeding.

24. A client is preparing to undergo an intravenous cholangiography. What instructions


should be given to the client before the procedure?
A. “The entire test will take less than 30 minutes.”
B. “You may feel the urge to defecate during the procedure.”
C. “You will feel a warm or flushing sensation when the contrast medium is injected.”
D. “The examination table will be tilted in several different positions to facilitate passage of the
contrast medium.”

ANS: C
The client is instructed to expect a warm or flushing sensation with injection of the contrast medium. The
test takes 2 to 4 hours to complete.

25. The nurse is preparing a client for a CT (computed tomography) scanning of the abdomen
with contrast. What question should be asked before the examination?
A. “Are you allergic to iodine or seafood?”
B. “Have you had anything to eat or drink within the past 12 hours?”
C. “Have you finished drinking all the required fluid?”
D. “Can you tolerate being tilted from side to side during the procedure?”

ANS: A
Allergies to iodine or seafood can mean a cross-allergic reaction to the contrast dye used for CT scans.
Clients reporting such allergies are scheduled for CT without contrast to avoid anaphylactic reactions.

26. A client has returned to the unit after having an EGD (esophagogastroduodenoscopy) to
evaluate a gastric ulcer. What safety measure should be instituted for this client?
A. The client should be placed in lithotomy position to prevent aspiration.
B. The client should be supine for 8 hours after the examination.
C. The client should be kept NPO until the gag reflex returns.
D. The client should be given midazolam (Versed) to reverse the sedation.

ANS: C
The client should be kept NPO until the gag reflex returns. For an EGD, the throat is anesthetized to
facilitate passage of the tube. The client's gag reflex will therefore be relaxed, and aspiration could occur.

27. Twenty-four hours after endoscopic retrograde cholangiopancreatography (ERCP), a


client develops left upper quadrant abdominal pain and has a temperature of 101° F (38.3° C). What is the
nurse’s best action?
A. Administer acetaminophen for control of fever and pain.
B. Document the finding, because it is a normal postprocedure event.
C. Notify the health care provider.
D. Increase the IV fluid rate.

ANS: C
The client who has undergone an ERCP may develop complications such as perforation or sepsis
manifested by fever and abdominal pain. The nurse should report these symptoms to the health care
provider immediately.

28. A client undergoing a colonoscopy experiences a decrease in pulse rate from 76


beats/min to 50 beats/min. What medication should the nurse be prepared to administer?
A. Atropine
B. Lidocaine
C. Epinephrine
D. Procainamide

ANS: A
The nurse should prepare to administer atropine, because a vasovagal reflex can be stimulated during the
procedure, leading to bradycardia.

29. After a colonoscopy, a client reports that he is experiencing abdominal fullness and
cramping. What is the nurse’s best action?
A. Insert a rectal tube to assist in passing of flatus.
B. Notify the physician immediately because a bowel perforation is suspected.
C. Have the client consume only liquids for 4 to 6 hours after the test.
D. Explain to the client that this feeling can be expected for several hours after the test.

ANS: D
Feelings of abdominal fullness, cramping, and the passing of flatus are normally expected after a
colonoscopy.
30. The nurse is preparing a client for an ultrasound of the abdomen. What statement by the
client indicates a need for further teaching?
A. “I will need to consume extra liquids.”
B. “I will empty my bladder completely before the test.”
C. “I will lie on my back during the test.”
D. “I will lie still during the test.”

ANS: B
A full bladder is necessary for accurate visualization.

OTHER

1. Which statements regarding the functions of the esophagus are true? (Select all that
apply.)
A. The esophagus secretes enzymes necessary for digestion of carbohydrates.
B. The esophagus propels food from the pharynx to the stomach.
C. The esophagus prevents reflux from the duodenum.
D. The esophagus secretes mucus to lubricate food.
E. The esophagus begins the breakdown of fats and proteins.

ANS:
B, D
Rationale: The esophagus secretes mucus to lubricate the food and aids in transport of the food bolus to the
stomach.

2. Percussion of the abdomen provides information regarding which of the following?


(Select all that apply.)
A. Size of organs
B. Presence of fluid
C. Presence of masses
D. Degree of infection
E. Degree of bruit
F. Absence of bowel sounds

ANS:
A, B, C, D
Rationale: Percussion helps determine organ size and the presence of masses, fluid, and air.

Chapter 58: Interventions for Clients with Esophageal Problems

MULTIPLE CHOICE

1. What is the pH range of the distal esophagus?


A. 1.5-2.0
B. 3.0-4.5
C. 4.5-6.0
D. 6.0-7.0

ANS: D
The pH of the lower esophagus is neutral (normal).

2. Which statement is true?


A. Esophageal reflux occurs in the presence of decreased lower esophageal sphincter tone.
B. Esophageal reflux occurs in the presence of spasms of the lower esophageal sphincter tone.
C. Esophageal reflux occurs in the presence of tensing of the upper esophageal sphincter.
D. Esophageal reflux occurs in the presence of decreased intra-abdominal pressure.

ANS: A
Esophageal reflux can occur when the intra-abdominal pressure is elevated or when the sphincter tone of
the LES is decreased.

3. Which of the following clients is most at risk for gastroesophageal influx?


A. A client who drinks decaffeinated beverages
B. A client who is underweight.
C. A client taking oral hypoglycemic agents
D. A client who has a nasogastric tube

ANS: D
A nasogastric tube keeps the cardiac sphincter open, allowing acidic contents from the stomach to enter the
esophagus.

4. The client with esophageal reflux who experiences regurgitation while lying flat is at risk
for which complication?
A. Erosion
B. Bleeding
C. Aspiration
D. Odynophagia

ANS: C
Regurgitation of stomach contents while the client is recumbent poses a risk of aspiration for the client.

5. Which is the priority assessment in the client experiencing regurgitation?


A. Auscultation for crackles
B. Inspection of the oral cavity
C. Palpation of the cervical lymph nodes
D. Culture of the throat for bacterial infection

ANS: A
The client with regurgitation is at risk of aspiration, pneumonia, and bronchitis. The nurse should auscultate
the lungs for crackles, an indication of aspiration.
6. Which client response to Bernstein’s test would confirm the diagnosis of esophagitis?
A. The client reports dysphagia during the test.
B. The client reports heartburn during the test.
C. The client reports no symptoms during the test.
D. The client reports painful swallowing during the test.

ANS: B
If Bernstein’s test result is positive, clients with esophagitis experience heartburn as the acidic solution is
infused.

7. The most accurate method of diagnosing gastroesophageal reflux disease (GERD) is


which of the following?
A. Endoscopy
B. Schilling’s test
C. 24-hour ambulatory pH monitoring
D. Stool testing for occult blood

ANS: C
The most accurate method of diagnosing gastroesophageal reflux disease is 24-hour ambulatory pH
monitoring.

8. Which of the following complications should the nurse be alert for in the client with
Barrett’s esophagus who is complaining of dysphasia?
A. Achalasia
B. Esophageal stricture
C. Paraesophageal hernia
D. Oropharyngeal dysphagia

ANS: B
In Barrett’s esophagus, fibrosis and scarring accompanying the healing process can cause esophageal
stricture and lead to difficulty in swallowing.

9. Which dietary guide instructions should the nurse include in a teaching plan for the client
with gastroesophageal reflux?
A. “Eat four to six small meals each day.”
B. “Eat a small evening snack 1 to 2 hours before bed.”
C. “Drink carbonated beverages between meals only.”
D. “You may include orange or tomato juice with your breakfast.”

ANS: A
The client is instructed to eat four to six small meals daily rather than three larger meals to avoid pressure
in the stomach and delayed gastric emptying, which can increase reflux. Evening snacks, carbonated
beverages, and acidic foods also should be avoided.

10. What intervention should the nurse suggest to a client to prevent nighttime reflux?
A. “Sleep in the right lateral decubitus position.”
B. “Have a light evening snack before bedtime.”
C. “Have alcoholic beverages early in the evening.”
D. “Elevate the head of the bed 8 to 12 inches for sleep.”

ANS: D
Elevation of the head of the bed 8 to 12 inches for sleep is helpful in preventing nighttime reflux episodes
related to the recumbent position. Wooden blocks or foam wedges can be used to achieve this level of
elevation.

11. A client with severe GERD is still having symptoms of reflux despite taking omeprazole
(Prilosec) 20 mg daily. What is the nurse’s best action?
A. Document the finding as the only action.
B. Notify the health care provider.
C. Instruct the client to stop the medication immediately.
D. Instruct the client to take an antacid in addition to the omeprazole.

ANS: B
Omeprazole is a proton pump inhibitor that acts to reduce gastric acid secretion. If once-daily dosing fails
to control the client’s symptoms, the nurse should notify the health care provider, because the dose can be
increased to twice daily for better symptom control.

12. What instructions should the nurse provide to the client initiating treatment with
metoclopramide (Reglan) for GERD?
A. “Take this medication 60 minutes before each meal.”
B. “This medication will promote healing of esophageal tissue if taken at regular intervals.”
C. “This medication can make you feel tired.”
D. “This medication can cause abdominal cramping and diarrhea.”

ANS: C
Treatment with metoclopramide is associated with neurologic and psychotropic side effects, such as
anxiety, fatigue, ataxia, and hallucinations.

13. A client who has undergone Nissen fundoplication for GERD is ready for discharge
home. What instructions should be included in the discharge teaching for this client?
A. “You will no longer need any medication.”
B. “Avoid spicy foods because they can irritate the suture line.”
C. “You should take antireflux medications only when you eat a large meal.”
D. “You will need to continue to watch your diet and take your medication.”

ANS: D
There is a high percentage of recurrence of reflux after this type of surgery, so clients are encouraged to
continue antireflux regimens of medication and diet control.

14.In caring for a client with a rolling hernia, the nurse should be alert for which potential
complication?
A. Reflux
B. Vomiting
C. Pneumonia
D. Obstruction
ANS: D
A rolling hernia causes the fundus and portions of the stomach’s greater curvature to roll into the thorax
next to the esophagus, predisposing the client to volvulus, obstruction, and strangulation.

15. Which of the following statements made by the client indicates an understanding of the
management of hiatal hernia?
A. “I will lie flat for 30 minutes after each meal.”
B. “I will remain upright for several hours after each meal.”
C. “I will have my blood count done in 2 weeks to check for anemia.”
D. “I will sleep at night lying on my left side to prevent nighttime reflux.”

ANS: B
Clients with a sliding hernia experience GERD, and positioning, for these clients, is an important
intervention. The client should be taught to sleep with the head of the bed elevated, to remain upright after
meals, and to avoid straining or restrictive clothing.

16. What nursing intervention is aimed at preventing serious complications in the client with
a sliding hernia surgical repair?
A. Range-of-motion exercises to the lower extremities
B. Elevation of the head of the bed to 30 degrees
C. Monitoring of input and output
D. Assessment of bowel sounds

ANS: B
The prevention of respiratory complications is the primary focus of postoperative care. The high incision
makes taking deep breaths extremely painful for this client. By elevating the head of the bed to at least 30
degrees, the nurse promotes lung expansion in the client.

17. A client who has undergone a fundoplication wrap for hernia repair has returned from the
postanesthesia care unit with a nasogastric tube draining dark brown fluid. What is the nurse’s priority
action at this time?
A. Notify the physician.
B. Document the finding as the only action.
C. Clamp the nasogastric tube for 30 minutes.
D. Irrigate the nasogastric tube with normal saline.

ANS: B
After fundoplication, drainage from the nasogastric tube is initially dark brown with old blood. This finding
is expected and requires only documentation. The drainage should become yellow-green within 8 hours
after surgery.

18. For the client who has undergone fundoplication surgery, which statement made by the
client indicates a need for further teaching regarding dietary instructions?
A. “I will eat three meals per day.”
B. “I will drink only decaffeinated coffee.”
C. “I will begin oral intake by taking only clear fluids.”
D. “I will eliminate carbonated beverages from my diet.”
ANS: A
Once the client can tolerate clear fluids, the diet may be advanced. The client should eliminate alcohol,
caffeine, and carbonated beverages from the diet. The client should be instructed to eat smaller, more
frequent meals because the food storage area of the stomach is reduced by the surgery.

19. A client who has undergone a fundoplication wrap for hernia repair is preparing for
discharge. Which discharge instructions should be included in a teaching plan for this client?
A. “You should avoid taking stool softeners.”
B. “You may eat three normal-sized meals per day.”
C. “Notify your physician if you develop symptoms of a cold.”
D. “You may return to your former level of activity as soon as you are discharged.”

ANS: C
The client is instructed to report cold or flulike symptoms, because persistent coughing associated with
these conditions can cause dehiscence of the incision.

20. Which of the following complications would the nurse expect to observe in the client
with progressive dysphagia and a history of achalasia?
A. Aneurysm
B. Weight loss
C. Pneumothorax
D. Esophageal varices

ANS: B
Clients with progressive dysphagia can develop weight loss from the inability to take adequate nutrition.

21. The nurse is caring for a client who has undergone esophageal dilation for achalasia. Two
hours later, the client develops chest and shoulder pain. What would be the nurse’s best action?
A. Administer an analgesic.
B. Document the finding as the only action.
C. Reposition the client.
D. Notify the physician.

ANS: D
The client may be experiencing complications of the procedure, such as bleeding and perforation. These
complications require immediate intervention.

22. Which client is at highest risk for the development of esophageal cancer?
A. 45-year-old Asian American man who consumes pickled foods
B. 23-year-old white woman who is taking oral contraceptives
C. 60-year-old Scandinavian American woman with breast cancer
D. 72-year-old Native American man with diabetes mellitus

ANS: A
Esophageal cancers are highest in African Americans, in people from certain areas of China, Japan, and the
Caspian Sea, and in people from Africa. The disease also is associated with ingestion of pickled foods,
which have high levels of nitrosamines.
23. The nurse is collecting the initial history from a client with suspected esophageal cancer.
What factor in this client’s history increases the risk of developing esophageal cancer?
A. A high-stress occupation
B. A preference for high-fat foods
C. A 20 pack-year smoking history
D. A history of myocardial infarction

ANS: C
In the United States, the two most important factors in the development of esophageal cancer are tobacco
use and alcohol ingestion.

24. The nurse is performing an assessment of a client with suspected esophageal cancer.
Which statement made by the client is indicative of a more advanced disease?
A. “I have difficulty swallowing solids, particularly meat.”
B. “I usually have a sticking feeling in my throat.”
C. “I have difficulty swallowing soft foods.”
D. “I have difficulty with swallowing liquids.”

ANS: D
Dysphagia does not usually present until the esophageal lumen is 60% occluded. It begins with a sticking
sensation in the throat and dysphagia for solids, followed by dysphagia for soft foods. The client with
dysphagia for liquids has the most advanced disease.

25. Which nursing diagnosis would be considered a priority in planning the care of a client
with esophageal cancer?
A. Imbalanced Nutrition: Less than Body Requirements
B. Anticipatory Grieving
C. Risk of Aspiration
D. Acute Pain

ANS: A
The priority for care of a client with esophageal cancer is Imbalanced Nutrition: Less than Body
Requirements related to impaired swallowing. Fear of choking and inability to take adequate nutrition
because of tumor obstruction contributes to weight loss.

26. A client with esophageal cancer and dysphagia states it has become more difficult to
swallow, and the client has experienced several choking episodes during meals. What strategy would the
nurse recommend to assist this client in obtaining adequate nutrition?
A. Encourage the client to eat semisoft foods and thickened liquids.
B. Tell the client that artificial feeding will now be required.
C. Instruct the client to drink only clear liquids.
D. Monitor caloric intake.

ANS: A
The client with dysphagia is usually able to tolerate swallowing semisoft foods and/or thickened liquids to
obtain adequate intake. Clear liquids alone may not provide enough calories or nutrients. Efforts are made
to preserve swallowing ability as long as possible, although in the case of complete obstruction, a feeding
tube may be necessary.
27. In assessing a client with esophageal cancer being treated with radiation therapy, what
finding would alert the nurse to a possible complication of this treatment?
A. Redness of the skin at the site of radiation
B. Worsening of dysphagia or odynophagia
C. Development of nausea or vomiting
D. A profound feeling of tiredness

ANS: B
Worsening of the client’s symptoms may signal the development of monilial esophagitis, a fungal infection
that can develop after radiation to the esophagus.

28. A client has undergone an esophagogastrostomy for cancer of the esophagus. Which
action should the nurse take to support the respiratory care of this client?
A. Assess the client’s breath sounds every 4 hours.
B. Perform chest physiotherapy every 6 hours.
C. Maintain the client in a supine position.
D. Administer analgesia regularly.

ANS: D
Respiratory care is the highest postoperative priority. Incisional support and adequate analgesia are crucial
for effective coughing and deep breathing. As long as vital signs are stable, the nurse administers analgesia
regularly to assist the client in performing deep breathing, turning, and coughing routines.

29. On assessment, the nurse notes the presence of bloody nasogastric tube drainage from a
client who underwent an esophagogastrostomy 2 days ago. What conclusion should the nurse draw from
this assessment?
A. The client’s nasogastric tube requires irrigation.
B. The drainage is as expected for this time period.
C. The client’s nasogastric tube requires repositioning.
D. The client has developed bleeding at the suture line.

ANS: D
The initial nasogastric drainage appears bloody, but should turn a yellow-green color by the end of the first
postoperative day. If the bloody color continues, it may indicate bleeding at the suture line.

30. The client recovering from an esophagogastrostomy is preparing for discharge. What
instructions should be included in the dietary teaching for this client?
A. “Eat only three meals per day.”
B. “Lie flat after meals to prevent vomiting.”
C. “Drink fluids between, rather than with, meals.”
D. “Avoid high-protein foods because they are irritating.”

ANS: C
The client is taught to drink fluids between rather than with meals to prevent diarrhea resulting from
vagotomy syndrome. The client also should sit upright during and after meals and eat a high-protein diet of
six to eight meals per day.
31. The home care nurse is assessing a client who is 10 days postesophagogastrostomy for
esophageal cancer. Assessment findings include a temperature of 38° C (101° F), pulse rate of 110, and
respirations of 28. What would be the nurse’s best action?
A. Notify the physician.
B. Administer acetaminophen 500 mg every 4 hours.
C. No action is needed; these findings are expected.
D. Administer acetaminophen 500 mg and request an order for an antianxiety agent.

ANS: A
Symptoms such as fever, tachycardia, tachypnea, and fluid collection can be indicative of an anastomosis
leak. The physician should be notified immediately.

32. Which dietary instructions should be included in a teaching plan for the client newly
diagnosed with diverticula?
A. “You should eat soft foods and smaller meals because they are better tolerated.”
B. “You have no dietary restrictions; you may eat anything you wish.”
C. “You should avoid drinking liquids with your meals.”
D. “You should avoid dairy products.”

ANS: A
Soft foods and smaller meals assist in reducing the symptoms of pressure and reflux that accompany
diverticula.

33. What complication should the emergency department nurse anticipate in the client with a
chemical injury to the esophagus after ingestion of an alkaline substance?
A. Infection
B. Stricture
C. Aspiration
D. Perforation

ANS: D
Although all these complications are possible, ingestion of alkaline substances is dangerous because of
their potential to penetrate the esophagus fully, leading to perforation.

OTHER

1. The nurse is obtaining the history of a client with a sliding hernia. Which of the following
symptoms would the nurse expect to see in this client? (Select all that apply.)
A. Reflux
B. Bleeding
C. Dysphagia
D. Belching
E. Breathlessness
F. Vomiting

ANS:
A, C, D, E
Rationale: Clients with sliding hernias often experience symptoms of reflux, pain, dysphagia, and belching.
Some clients may experience breathlessness or a feeling of suffocation.
Chapter 61: Interventions for Clients with Inflammatory Intestinal Disorders

MULTIPLE CHOICE

1. What clinical manifestations represent the early symptoms of classic appendicitis?


A. Crampy periumbilical pain
B. Severe lower right quadrant pain
C. Lower right quadrant pain that decreases with movement
D. Abdominal pain that increases with flexion of the knees

ANS: A
In classic appendicitis, the initial symptom is mild, crampy epigastric or periumbilical pain.

2. The client reports the presence of lower right abdominal pain for 2 days and, on
examination, the client’s abdomen is rigid, with tense positioning. What conclusion can the nurse draw
from this information?
A. The client is experiencing an adverse reaction to opioids.
B. The client is experiencing an exacerbation of Crohn’s disease.
C. The client is experiencing a remission of appendicitis symptoms.
D. The client is experiencing perforation of the appendix and peritonitis.

ANS: D
In clients who experience the symptoms of appendicitis for more than 48 hours, the incidence of peritonitis
is very high. Symptoms such as pain accompanied by tenseness and guarding are indicative of perforation
accompanied by peritonitis.

3. Which of the following preoperative interventions would be contraindicated for the client
with acute appendicitis?
A. Keeping the client NPO
B. Administering IV fluids
C. Placing a heating pad on the abdomen
D. Placing the client in a semi-Fowler’s position

ANS: C
Placing heat on the abdomen increases circulation to the area, which increases inflammation and possibly
contributes to perforation.

4. Which is the classic symptom of peritonitis?


A. Absence of bowel sounds
B. Elevated BUN level
C. Abdominal wall rigidity
D. Temperature higher than 101o F (38.3° C)
ANS: C
Abdominal wall rigidity is a classic finding in peritonitis and is often referred to as a “boardlike” abdomen.

5. In performing wound care with peritoneal irrigation through a drain, which finding would
alert the nurse that the client is retaining the irrigant?
A. Hyperactive bowel sounds in all quadrants
B. Tympany to percussion of the abdomen
C. Abdominal distention and pain
D. Tenting of the abdominal skin

ANS: C
The presence of abdominal distention and pain is an indication that the client may be retaining the irrigant.
The nurse also monitors irrigant intake and output.

6. A 76-year-old client has been ill with fever and diarrhea for several days and is now
diagnosed with gastroenteritis. What is this client is at risk for?
A. Dehydration
B. Hypertension
C. Rectal abscess
D. Mucus in the stools

ANS: A
Older adults with gastroenteritis are particularly susceptible to dehydration.

7. What nursing intervention would be the priority for an 82-year-old woman admitted with
severe gastroenteritis and who is having up to 15 watery stools per day?
A. Replacing fluids
B. Ensuring skin care
C. Changing positions frequently
D. Providing a bedside commode

ANS: A
Although the remaining answers are good nursing interventions, the priority intervention for an older adult
client with severe gastroenteritis is fluid replacement. Older clients are at a high risk for rapidly developing
dehydration and subsequent shock.

8. The laboratory testing of a client who is having approximately 20 foul-smelling stools per
day reveals the presence of WBCs and RBCs in the stool. What organism is the most likely cause of this
client’s gastroenteritis?
A. Escherichia coli
B. Staphylococcus aureus
C. Shigella
D. Campylobacter

ANS: D
Campylobacter gastroenteritis causes foul-smelling diarrhea with up to 20 to 30 stools per day for 7 days.
Both RBCs and WBCs are present in a Gram stain of the stools.

9. Which dietary teaching is priority for the client with mild to moderate gastroenteritis
during the acute phase of the illness?
A. “Eat and drink every 2 hours even if nausea and vomiting persists.”
B. “Drink large quantities of clear fluids.”
C. “Do not drink water.”
D. “Eat a regular diet.”

ANS: C
The client is discouraged from drinking plain water because electrolyte replacement will be needed. The
client may drink electrolyte-containing solutions, such as Gatorade.

10. A client admitted with gastroenteritis is preparing for discharge. What statement made by
the client indicates a need for further skin care teaching?
A. “I will take a sitz bath three times per day.”
B. “I will clean the rectal area with warm water.”
C. “I will clean the rectal area liberally with toilet tissue.”
D. “I will dry the skin around the buttocks following cleansing.”

ANS: C
The skin of the buttocks and rectal area becomes very sensitive and can become excoriated with diarrhea.
The nurse encourages the client to avoid toilet tissue and harsh soaps, which increase irritation. The area
should be cleansed with warm water and dried with absorbent cotton.

11. The clinical manifestations of ulcerative colitis include:


A. The client may have five or six soft stools per day.
B. The client may have 10 to 20 steatorrheal stools per day.
C. The client may have 10 to 20 liquid, bloody stools per day.
D. The client may have abdominal pain, but the stool appearance is normal.

ANS: C
Ulcerative colitis is characterized by 10 to 20 liquid, bloody stools per day. The colon appears red and
hemorrhagic.

12. Which laboratory finding would be anticipated in the client admitted with ulcerative
colitis?
A. A decreased WBC
B. An increased total protein level
C. An elevated erythrocyte sedimentation rate
D. An increased serum potassium level

ANS: C
An increased ESR secondary to the inflammatory process associated with ulcerative colitis is a common
finding during exacerbation of the disease.

13. What should the client with ulcerative colitis who is prescribed sulfasalazine (Azulfidine)
be taught?
A. “Take this medication with food.”
B. “Crush the tablets for easier swallowing.”
C. “Decrease fluid intake while taking this medication.”
D. “Discontinue this medication when symptoms subside.”

ANS: A
Sulfasalazine should be taken after meals or with food to prevent GI irritation. These enteric-coated tablets
should not be crushed. The medication should be taken even if the client feels well. Fluid intake should be
increased to prevent crystallization of the urine.

14. Which clinical manifestation would indicate a possible side effect of oral mercaptopurine
(Purinethol)?
A. Lower extremity edema
B. Tachycardia
C. Sore throat
D. Agitation

ANS: C
Mercaptopurine causes bone marrow suppression, which can predispose the client to infection. Any report
of illness—sore throat, cough, or fever—should be reported.

15. Which of the following menu options would be appropriate for the client on a low-
residue diet?
A. Fried chicken, mashed potatoes, gravy, and fruit juice
B. Cream of tomato soup, mixed green salad, and milk
C. Baked fish, steamed asparagus, dinner roll, and tea
D. Roasted chicken, steamed spinach, rice, and a glass of wine

ANS: C
Fried foods, raw vegetables, and alcoholic beverages are contraindicated in ulcerative colitis. This client
should eat a low-residue diet, and all vegetables should be canned or cooked.

16. A client with an exacerbation of ulcerative colitis has been placed on total parenteral
nutrition (TPN). The client asks why nutrition is being supplied in this manner and not by mouth. What is
the nurse’s best response?
A. “TPN contains a high percentage of glucose that is more readily absorbed into the bloodstream
than into the ulcerated colon.”
B. “TPN will be given in addition to your meals to help you gain any weight that you may have lost
through diarrhea.”
C. “TPN is considered an elemental formula and, as such, is easier to digest.”
D. “TPN will be given during this period to allow your bowel to rest.”

ANS: D
Bowel rest during severe exacerbations of ulcerative colitis is part of the nonsurgical management of the
disease.

17. While performing the initial postoperative assessment of a client who has undergone a
total proctocolectomy, with placement of a permanent ileostomy, the nurse notes that the drainage from the
ileostomy appears loose, dark green in color, and contains some blood. What is the nurse’s best action at
this time?
A. Notify the physician.
B. Document the finding as the only action.
C. Irrigate the ileostomy.
D. Send a stool sample for culture and sensitivity.

ANS: B
The initial drainage from the ileostomy appears loose, dark green, and may contain some blood. The nurse
should document this normal finding. The stool consistency and color will change over time to a yellow-
green or brown.

18. Which instructions should be included in a teaching plan for a client who has undergone
a total colectomy and placement of a continent ileostomy?
A. “Empty the pouch only once per day.”
B. “Do not place any type of dressing over the ileostomy.”
C. “Place the external pouch directly over the ileostomy opening.”
D. “You will feel a full sensation when the pouch needs to be emptied.”

ANS: D
The client experiences a sensation of fullness when the pouch needs to be emptied. A continent ileostomy
does not require the client to wear an external pouch; only a small dressing is necessary. The pouch is
emptied several times per day.

19. The client has undergone a total colectomy with an ileoanal reservoir. What is the priority
nursing intervention at this time?
A. Consulting with an enterostomal therapist
B. Providing frequent perineal care
C. Monitoring of urinary output
D. Managing constipation

ANS: B
A client who has had a total colectomy with an ileoanal reservoir does not have an ostomy because the
ileum is sutured into the anal canal. The client will experience perineal irritation as a result of frequent,
loose stools, and frequent perineal care is needed to prevent skin breakdown.

20. What medication would the nurse expect to administer to the client with ulcerative colitis
who complains of painful abdominal cramping?
A. Meperidine (Demerol)
B. Methylprednisolone sodium succinate (Solu-Medrol)
C. Sulfasalazine (Azulfidine)
D. Dicyclomine (Bentyl)

ANS: D
Dicyclomine (Bentyl) is often prescribed for the relief of abdominal cramping secondary to ulcerative
colitis. Opioids are usually contraindicated because they can disguise complications.
21. Which of the following is a complication of Crohn’s disease?
A. Arthritis
B. Weight gain
C. Fistula formation
D. Gastrointestinal tuberculosis

ANS: C
Complications of Crohn’s disease are fistulas, hemorrhage, and obstruction.

22. What clinical manifestation is unique to an exacerbation of Crohn’s disease?


A. Fever
B. Diarrhea
C. Steatorrhea
D. Abdominal pain

ANS: A
With exacerbation of the disease, the client will have a fever in addition to the usual manifestations of the
illness (diarrhea, steatorrhea, abdominal pain).

23. Which of the following alterations in laboratory values would indicate the client is
experiencing an exacerbation of Crohn’s disease?
A. An elevated WBC
B. An elevated ESR
C. Decreased serum albumin level
D. Decreased hematocrit

ANS: B
With an exacerbation of Crohn’s disease, the nurse can expect to find an elevated ESR (erythrocyte
sedimentation rate), indicating the presence of inflammation. Although the WBC may be elevated and
albumin and hematocrit will be decreased in Crohn’s disease, they are not markers of disease exacerbation.

24. In the client with Crohn’s disease experiencing severe diarrhea, what should the nurse
monitor for as the priority assessment?
A. Cardiac dysrhythmias
B. Skin irritation
C. Anorexia
D. Anemia

ANS: A
Although the client with severe diarrhea may experience skin irritation and anemia, the client is most at risk
of cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client
should have electrolyte levels monitored, and electrolyte replacement may be necessary.

25. A client with Crohn’s disease develops a fever of 101° F (38.3° C) and periumbilical
pain. What is the nurse’s best action?
A. Administer the PRN order for acetaminophen.
B. Apply moist heat to the periumbilical region.
C. Notify the health care provider.
D. Increase the IV fluid rate.

ANS: C
Periumbilical pain and fever are signs of fistula formation or severe inflammation, and should be reported
to the health care provider.

26. A client with Crohn’s disease has strictures in the colon. Based on this finding, for which
of the following complications is the client most at risk?
A. Peritonitis
B. Obstruction
C. Malabsorption
D. Fluid imbalance

ANS: B
The presence of strictures (also known as string sign) predisposes the client to intestinal obstruction.

27. A client with fistula secondary to Crohn’s disease is being treated with a course of
glucocorticoids. For which complication of this treatment is the client at risk?
A. Constipation
B. Hypoglycemia
C. Dyspnea
D. Sepsis

ANS: D
Glucocorticoids are effective in treating Crohn’s disease but must be used very cautiously when fistula or
abscess is present, because they mask the signs of infection and sepsis can result.

28. Which of the following nursing interventions would be a priority for the client with
Crohn’s disease who has developed a fistula?
A. Positioning the client to allow gravity drainage of the fistula
B. Monitoring the client’s hematocrit and hemoglobin
C. Recording pulse oximetry readings every 4 hours
D. Maintaining adequate nutrition

ANS: D
The client with Crohn’s disease is already at risk for malabsorption and malnutrition. Malnutrition impairs
the healing of the fistula and immune responses; therefore, maintaining adequate nutrition is a priority for
this client. The client will require 3000 calories/day to promote healing of the fistula.

29. What instructions should be included in a health teaching plan for the client with Crohn’s
disease?
A. “Working full time is not advisable for someone with Crohn’s disease.”
B. “You may decrease your medications slowly as symptoms subside.”
C. “You should have a yearly colonoscopy.”
D. “You should eat a high-residue diet.”

ANS: C
Long-term inflammatory bowel disease increases the risk of colon cancer. The client is advised to have a
yearly colonoscopy.

30. An older adult client with diverticulitis is being prepared for discharge. Which of the
following statements made by the client indicates a need for further teaching?
A. “I will avoid straining when bending.”
B. “I will use a laxative to avoid constipation.”
C. “I will increase the amount of fiber in my diet.”
D. “I will notify the doctor if I notice blood in my stools.”

ANS: B
Laxatives and enemas increase intraluminal pressure and are therefore discouraged.

31. Which of the following meals would be appropriate for the nurse to recommend to a
client with diverticulosis?
A. A sandwich of luncheon meat on whole wheat bread, steamed carrots, and a raw apple
B. Sandwich of chicken salad on white bread, creamed soup, and hot tea
C. Fried shrimp, lettuce and tomato salad, and a dinner roll
D. Roasted chicken, potato salad, and a glass of milk

ANS: A
The client is encouraged to eat a diet high in fiber that would include whole-grain breads, root vegetables,
and fruit with the skin on.

32. A client has undergone an incision and drainage of an anorectal abscess. Which of the
following nursing interventions would be appropriate for this client?
A. Pack the rectum with iodoform gauze.
B. Assist the client with sitz baths several times per day.
C. Administer daily enemas to keep the surgical area free of stool.
D. Place the client in a prone position for 8 hours after the surgery.

ANS: B
Sitz baths help promote perineal comfort.

33. A client diagnosed with Giardia lamblia infection is at risk for which of the following?
A. Intractable nausea and vomiting
B. Malabsorption syndrome
C. Peptic ulcer disease
D. Toxic megacolon

ANS: B
G. lamblia infection results in severe diarrhea and malabsorption of vitamin B12, fats, and protein.

34. A client with enterobiasis asks how spread of the infestation to other family members can
be prevented. What is the nurse’s best response?
A. “Wear a mask over your mouth when in close contact with others.”
B. “Wash your hands before meals and after bowel movements.”
C. “Sleep in a separate room until the infection subsides.”
D. “Vacuum the home thoroughly.”

ANS: B
This infestation is acquired by the oral-fecal route. The client is instructed to wash his or her hands before
meals and after each bowel movement with an antibacterial soap to prevent spread of the infestation.

35. A client is brought to the emergency room with an abrupt onset of vomiting, abdominal
cramping, and diarrhea 2 hours after eating food at a picnic. Which of the following infectious agents
would the nurse suspect as the probable cause?
A. Clostridium botulinum
B. Staphylococcus
C. Giardia lamblia
D. Salmonella

ANS: B
Staphylococcus can be found in meat and dairy products and can be transmitted to people. Food poisoning
occurs, especially if foods are left unrefrigerated over a period of time.

OTHER

1. What laboratory data result would indicate complications of peritonitis? (Select all that
apply.)
A. A positive blood culture
B. A WBC count of 20,000
C. An elevated serum amylase level
D. The presence of WBCs in the urine

ANS:
A, B
Rationale: A positive blood culture suggests that the toxins or bacteria responsible for the peritonitis have
entered the bloodstream, causing septicemia. The WBC count elevates above 20,000.

2. Which clinical manifestation would the nurse consider normal for a client with
gastroenteritis? (Select all that apply.)
A. Diffuse abdominal pain
B. Rebound tenderness
C. Hyperactive bowel sounds
D. An elevated temperature
E. Steatorrhea
F. Diarrhea
ANS:
A, C, D, F
Rationale: The nurse would expect to find an elevated temperature, abdominal pain, and hyperactive bowel
sounds. Rebound tenderness is not normally present and is a sign of peritonitis.
Chapter 62: Interventions for Clients with Liver Problems

MULTIPLE CHOICE

1. What data in the client’s past history would predispose the client to Laënnec’s cirrhosis?
A. History of gallstones
B. History of alcohol abuse
C. History of viral hepatitis
D. History of heart disease

ANS: B
Laënnec’s cirrhosis, also known as alcoholic cirrhosis, is caused by the toxic effect of alcohol on the liver.
The nurse should ask the client about a history of alcohol use.

2. A client admitted with cirrhosis has an enlarged liver, which the nurse suspects is
congested with venous blood. Which clinical manifestation would support the nurse’s suspicion?
A. Left upper quadrant pain
B. Pulmonary congestion
C. Jaundice
D. Vomiting

ANS: B
Cardiac cirrhosis is characterized by an enlarged liver congested with venous blood, because the liver
serves as a reservoir for large amounts of venous blood that the heart cannot pump into the systemic
circulation. Clients with this type of cirrhosis have pulmonary congestion, such as crackles.

3. A client with end-stage cirrhosis develops severe vomiting. This client is at risk for what
complication?
A. Intrahepatic bile stasis
B. Bleeding esophageal varices
C. Decreased excretion of bilirubin
D. The accumulation of plasma within the peritoneal cavity

ANS: B
The portal hypertension that accompanies end-stage cirrhosis predisposes the client to esophageal varices.
These varices can rupture from increased pressure in the esophagus caused by coughing or vomiting.

4. Ascites occurs because the liver is unable to synthesize which of the following?
A. Glucose
B. Carbohydrates
C. Albumin
D. Bile

ANS: C
Increased hydrostatic pressure causes fluid to leak into the peritoneal cavity. This is combined with the
inability of the liver to synthesize albumin.
5. A client with end-stage cirrhosis and gastrointestinal bleeding becomes combative and
confused. What complication of cirrhosis may this client be experiencing?
A. Ascites
B. Coagulation defects
C. Transient ischemic attack
D. Portal-systemic encephalopathy

ANS: D
Although the client may already have ascites and coagulation defects, a client with end-stage cirrhosis who
develops a GI bleed is at increased risk of portal-systemic encephalopathy, because this causes an increased
protein load in the intestines.

6. Which of the following clients with cirrhosis is at greatest risk for the development of
hepatorenal syndrome?
A. A client with early-stage Laënnec’s cirrhosis
B. A client taking acetaminophen for pain
C. A client with fatty infiltrates in the liver
D. A client eating a low-protein diet

ANS: B
Hepatorenal syndrome can be precipitated by clinical deterioration secondary to portal system
encephalopathy or by drugs such as Indocin (indomethacin), aspirin, or acetaminophen.

7. Which of the following findings alerts the nurse to the presence of hepatomegaly?
A. Dependent edema in the extremities and sacrum
B. Distended abdomen with bulging flanks
C. Shifting dullness with absent fluid wave
D. Dullness percussed over the liver

ANS: D
Hepatomegaly is assessed by palpation and percussion. In hepatomegaly, dullness is felt over the area of
the liver.

8. What assessment technique should be used to measure abdominal girth?


A. Measure the girth by placing the tape measure directly below the umbilicus.
B. Measure the girth while the client is in a standing position.
C. Measure the girth with the client lying on the left side.
D. Measure the girth at the end of exhalation.

ANS: D
The abdominal girth is measured at the end of exhalation, at the level of the umbilicus, while the client lies
flat.

9. What assessment indicates fetor hepaticus?


A. Purpuric lesions on the extremities
B. A fruity or musty breath odor
C. Warm and bright red palms
D. Jaundice of the sclera

ANS: B
Fetor hepaticus is a distinctive breath odor present with chronic liver disease. There is a fruity or musty
odor to the client’s breath.

10. To assess for the presence of asterixis, what should the client be instructed to do?
A. “Extend both arms in front of you with your feet together and close your eyes while standing.”
B. “Extend your arms at your sides, and hold this position for 30 seconds.”
C. “Extend your arm, flex your wrist upward, and extend your fingers.”
D. “Extend your arms in front of you with your palms upward.”

ANS: C
The correct technique for assessing the presence of asterixis is to extend the arm, dorsiflex the wrist, and
extend the fingers. The nurse then observes for the presence of rapid, nonrhythmic extensions and flexions.

11. Which laboratory data would indicate that the client with cirrhosis has advanced disease?
A. Elevated serum globulin level
B. Elevated serum ammonia level
C. Elevated serum protein level
D. Decreased lactate dehydrogenase level

ANS: B
The serum ammonia level is elevated in the presence of advanced disease because the conversion of
ammonia to urea for excretion is decreased.

12. Which laboratory finding would indicate a potential complication of liver disease?
A. Elevated AST and LDH levels
B. Elevated prothrombin time and INR
C. Decreased serum albumin and serum globulin levels
D. Decreased serum alkaline phosphatase and ALT levels

ANS: B
Elevated prothrombin time and INR are indications of clotting disturbances and alert the nurse to the
increased possibility of hemorrhage.

13. The laboratory data reveal a decreased fecal urobilinogen concentration. What clinical
manifestation would accompany this laboratory finding?
A. Clay-colored stools
B. Petechiae
C. Asterixis
D. Melena

ANS: A
When fecal urobilinogen levels are decreased as a result of biliary cirrhosis, the stools become light- or
clay-colored.
14. For the client with cirrhosis, what nursing intervention(s) would be most appropriate to
control fluid accumulation in the abdominal cavity?
A. Monitoring intake and output
B. Providing a low-sodium diet
C. Increasing PO fluid intake
D. Weighing the client daily

ANS: B
A low-sodium diet is one means of controlling abdominal fluid collection. Sodium intake may be restricted
to 500 mg to 1 g daily.

15. The client who is 1 hour postparacentesis is at risk for which of the following?
A. Hypovolemia
B. Systemic vasoconstriction
C. Increased intra-abdominal pressure
D. Rebound hypertension and fluid retention

ANS: A
Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hypovolemia
and possibly progress to vasodilation and shock.

16. What nursing intervention would be appropriate for the client who has just undergone a
paracentesis?
A. Inserting a Foley catheter
B. Maintaining the client on bedrest
C. Monitoring vital signs every 2 hours
D. Securing the trocar catheter to the abdomen with tape

ANS: B
Following paracentesis, the client’s vital signs are checked every 15 minutes and the client is maintained on
bedrest until vital signs are stable.

17. What clinical finding would the nurse expect to observe in the client who has just
undergone a peritoneovenous shunt placement?
A. Decreased level of consciousness
B. Decreased urinary volume
C. Increased blood pressure
D. Increased abdominal girth

ANS: C
With a peritoneovenous shunt placement, ascitic fluid is routed into the venous system, resulting in
vascular volume expansion. An increase in blood pressure is reflective of the increased volume.

18. A client is being treated for bleeding esophageal varices with an esophagogastric tube.
Which of the following nursing interventions is considered the priority for the care of this client?
A. Keeping the client sedated to prevent dislodgement of the tube
B. Maintaining balloon pressure between 15 and 20 mm Hg
C. Irrigating the gastric lumen with normal saline
D. Suctioning the oral cavity of secretions

ANS: D
Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral
secretions to prevent aspiration and occlusion of the airway.

19. A client with an esophagogastric tube suddenly experiences acute respiratory distress.
What should be the nurse’s immediate action?
A. Call the physician.
B. Cut the balloon ports and remove the tube.
C. Place the client in an upright position and apply oxygen.
D. Reduce the balloon pressure slightly using the sphygmomanometer.

ANS: B
In case of respiratory compromise in a client with an esophagogastric tube, the nurse should immediately
cut both ports with a pair of scissors that is kept at the bedside and remove the tube.

20. The physician has ordered vasopressin for a client with bleeding esophageal varices.
What is the action of vasopressin in the control of bleeding?
A. Constriction of preportal splanchnic arterioles
B. Inducing the release of clotting factors II, VII, IX, and X
C. Increasing portal pressure, thus decreasing portal blood flow
D. Decreasing contraction of smooth muscle in the vascular bed

ANS: A
Vasopressin acts to cause contraction of smooth muscle in the vascular bed, constricting preportal
splanchnic arterioles and decreasing blood flow to the abdominal organs, which in turn reduces portal
pressure and portal blood flow.

21. A client is receiving an infusion of vasopressin to treat bleeding esophageal varices.


Which clinical manifestation would indicate a serious adverse effect of the drug?
A. Acute nausea and vomiting
B. A pounding frontal headache
C. Vertigo and syncope
D. Midsternal chest pain

ANS: D
Midsternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by
vasopressin.

22. A client who underwent injection sclerotherapy 24 hours ago complains of chest
discomfort. What would be the nurse’s priority action?
A. Irrigate the NG tube.
B. Administer analgesia.
C. Apply oxygen via a nasal cannula.
D. Obtain an order for a 12-lead ECG.

ANS: B
The client who has undergone injection sclerotherapy may experience noncardiac chest discomfort for 24 to
72 hours after the procedure. The nurse assesses the client and administers an analgesic.

23. A client with severe esophageal varices is preparing for a transjugular intrahepatic portal
systemic shunt (TIPS) insertion. What preprocedure teaching should be included for this client?
A. “You will be discharged home after you are fully awake.”
B. “You will receive sedation, but the procedure may still be painful.”
C. “Your liver will function normally within 8 hours of having the shunt placed.”
D. “This procedure is considered a major surgery and will require general anesthesia.”

ANS: B
This procedure is performed in the radiology department under conscious sedation. However, the client is
instructed that, in spite of sedation, pain still may be experienced.

24. What clinical manifestation would indicate a possible complication of surgical bypass
shunting?
A. Renal artery bruits
B. Lower extremity edema
C. Decreased urinary output
D. Confusion or hallucinations

ANS: C
Following this procedure, clients are at risk of oliguria as a result of hypovolemia.

25. The nurse is caring for a client who has undergone a portal-systemic shunting procedure
and, on assessment of the client’s abdomen, the nurse notes an increase of abdominal girth. What is the
nurse’s priority action?
A. Document the finding as the only action.
B. Notify the physician.
C. Irrigate the shunt.
D. Clamp the shunt.

ANS: B
The client with increasing abdominal girth after a shunting procedure may be experiencing shunt failure or
excessive sodium administration. The physician should be notified to assess the shunt or re-institute
diuretic therapy.

26. A client with portal-systemic encephalopathy (PSE) is placed on a protein-restricted diet.


What is the rationale for this diet choice?
A. A low-protein diet will help restore liver function.
B. A low-protein diet will help reduce the amount of ammonia in the blood.
C. The diet will give the liver a chance to rest.
D. Once albumin levels are normal, less protein is needed to prevent fluid from leaking into the
abdomen.
ANS: B
A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A
low-protein diet helps reduce the excessive breakdown of protein into ammonia by intestinal bacteria.

27. A client who is being treated with lactulose reports experiencing several soft stools daily.
What is the nurse’s best response?
A. “This is the normal expected response to this medication.”
B. “You may take Kaopectate liquid three times daily for loose stools.”
C. “Do not take any more of the medication until I check with your physician.”
D. “We will need to send a stool specimen to the laboratory for culture and sensitivity.”

ANS: A
The purpose of administering lactulose to this client is to assist ammonia in leaving the circulatory system
through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing
a laxative effect and subsequently evacuating ammonia from the bowel.

28. After receiving lactulose the day before, the client reports having seven loose stools in
the past 12 hours. Based on this data, what laboratory findings would the nurse expect?
A. Hypokalemia
B. Hyponatremia
C. Hypercalcemia
D. Hyperglycemia

ANS: A
Because lactulose can cause the client to have several loose stools daily, the nurse should monitor serum
electrolyte levels, particularly the serum potassium level for hypokalemia.

29. A client diagnosed with hepatitis A asks how the infection may have been contracted.
What is the correct response?
A. “Some medications have been known to induce hepatitis A.”
B. “You may have been exposed through contaminated shellfish.”
C. “You may have been infected through a recent blood transfusion.”
D. “You have had Epstein-Barr virus before, and hepatitis A can co-infect you.”

ANS: B
The route of hepatitis A infection is through close personal contact or by ingesting contaminated water or
shellfish.

30. Which of the following clients is most at risk of developing hepatitis B?


A. 24-year-old college student who has had several sexual partners
B. 54-year-old woman who takes acetaminophen daily for headaches
C. 33-year-old business man who travels frequently
D. 72-year-old woman who has eaten raw shellfish

ANS: A
Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions,
hemodialysis, acupuncture, and the maternal-fetal route.

31. What clinical manifestations would the nurse expect in the client with chronic persistent
hepatitis?
A. The client has symptoms of hepatomegaly.
B. The client is asymptomatic.
C. The client is confused.
D. The client has asterixis.

ANS: B
The client with chronic persistent hepatitis is asymptomatic and physical assessment findings are usually
normal. Liver damage does not progress beyond the initial insult.

32. A client who is jaundiced and suspected of having contracted hepatitis B has been
admitted to the hospital. Which of the following nursing interventions would be most appropriate for this
client?
A. Encourage bedrest during this period.
B. Assist the client with ambulation to prevent thrombus formation.
C. Place the client on a clear liquid diet to reduce the workload of the liver.
D. Medicate the client with PRN prochlorperazine maleate (Compazine) to relieve nausea.

ANS: A
During the icteric phase, the client is placed on bedrest to rest the inflamed liver and promote hepatic cell
regeneration. Rest reduces the liver’s metabolic demands.

33. What statement made by a client who is traveling to a nonindustrialized country indicates
the need for further teaching regarding the prevention of viral hepatitis?
A. “When traveling out of the country, I will drink bottled water.”
B. “I will not share my drinking glass.”
C. “I should eat plenty of fresh fruit.”
D. “I will use careful handwashing.”

ANS: C
The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by
tap water.

34. Which serologic marker would the nurse expect to be present if the client is a carrier of
chronic hepatitis?
A. Anti-HCV antibodies
B. Anti-HBs antibodies
C. HBsAg antibodies
D. HAV antibodies

ANS: C
Persistent presence of the serologic marker HBsAg after 6 months indicates a carrier state or chronic
hepatitis.
35. What manifestation would indicate a serious side effect of ribavirin (Virazole)?
A. Anemia
B. Pedal edema
C. Sensory neuropathy
D. Decreased gastric motility

ANS: A
Ribavirin can cause sudden, severe anemia. The nurse should monitor the client’s complete blood count and
report anemia to the health care provider.

36. What clinical sign would alert the nurse to the presence of possible liver trauma?
A. Abdominal pain referred to the right shoulder
B. Right quadrant abdominal pain and swelling
C. Abdominal pain referred to the spine
D. Abdominal pain with accompanying rebound tenderness

ANS: A
One of the key features of liver trauma is abdominal pain that is increased on deep breathing and is referred
to the right shoulder (Kehr’s sign).

37. What is Kehr’s sign?


A. Abdominal pain referred to the right shoulder
B. Right quadrant abdominal pain and swelling
C. Abdominal pain referred to the spine
D. Abdominal pain with accompanying rebound tenderness

ANS: A
One of the key features of liver trauma is abdominal pain that is increased on deep breathing and is referred
to the right shoulder (Kehr’s sign).

38. Which of the following clients would be most at risk for the development of carcinoma of
the liver?
A. 58-year-old client with a history of diabetes mellitus
B. 28-year-old client with a history of blunt liver trauma
C. 65-year-old client with a history of cirrhosis
D. 80-year-old client with malnutrition

ANS: C
The risk of contracting a primary carcinoma of the liver is 40 times higher in clients with cirrhosis.

39. A client who underwent liver transplantation 2 weeks ago reports a temperature of 101° F
(38.3° C) and right flank pain. What would be the nurse’s best response?
A. “The immunosuppressive drugs you are taking may make you susceptible to infections.”
B. “You may be rejecting the transplanted liver and should go to the hospital immediately.”
C. “You should take an additional dose of cyclosporine today.”
D. “Take acetaminophen every 4 hours until you feel better.”
ANS: B
Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection, and the client should
be admitted to the hospital as soon as possible for intervention.

40. What medication should the nurse be prepared to administer for the client who is
experiencing transplant rejection?
A. Methylprednisolone
B. Cyclosporine
C. Azithromycin
D. Auranofin

ANS: A
Clients with transplant rejection may be treated with IV doses of methylprednisolone (Solu-Medrol).

Chapter 63: Interventions for Clients with Problems of the Biliary System and Pancreas

MULTIPLE CHOICE

1. What is the contributing factor to the development of acalculous cholecystitis?


A. Blockage by gallstones
B. Toxic reaction to drugs
C. Biliary stasis
D. Viral infection

ANS: C
Acalculous cholecystitis is caused by biliary stasis.

2. A client with acute cholecystitis resulting from obstruction of the cystic duct by
gallstones is at risk for which of the following?
A. Reflux of bile into the esophagus
B. Perforation of the gallbladder
C. Hepatomegaly
D. Malabsorption

ANS: B
In acute cholecystitis, trapped bile acts as a chemical irritant. Coupled with a distended gallbladder, edema,
and impaired circulation, tissue sloughing and gangrene can occur, leading to perforation.

3. The family of a client with chronic gallbladder inflammation and obstructive jaundice
asks why the client’s skin is itchy. What is the nurse’s best response?
A. “Bile salts accumulate on the skin causing it to itch.”
B. “Liver failure is imminent when metabolic products appear on the skin.”
C. “The bacteria responsible for inflammation of the gallbladder produce toxins on the skin.”
D. “The itching is caused by the breakdown of gallstones, which causes a hypersensitivity response.”

ANS: A
In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to
accumulate on the skin.

4. Jaundice occurs when the concentrate of bilirubin in the blood is which of the following?
A. 0.5–1.0 mg/dL
B. 1.0–1.5 mg/dL
C. 1.5–2.0 mg/dL
D. More than 2.5 mg/dL

ANS: D
When the concentration of bilirubin in the blood increases to more than 1.5 mg/dL, jaundice occurs.

5. What clinical manifestation would indicate that the client has chronic cholecystitis rather
than acute cholecystitis?
A. The absence of rebound tenderness
B. The absence of jaundice and bile duct obstruction
C. The presence of clay-colored stools and dark urine
D. The presence of hyperresonance to percussion of the abdomen

ANS: C
In chronic cholecystitis, bile duct obstruction results in the absence of urobilinogen to color the stool.
Excess circulating bilirubin turns urine dark and foamy.

6. Which of the following alterations in laboratory data are expected in a client admitted
with pancreatitis as a result of chronic cholecystitis?
A. Elevated serum and urine amylase levels
B. Elevated serum amylase and decreased serum lipase levels
C. Decreased direct and indirect serum bilirubin levels
D. Elevated serum alkaline phosphatase and decreased AST levels

ANS: A
With pancreatic involvement, serum and urine amylase levels are elevated.

7. What dietary teaching should be included in the discharge plan for a client with acute
cholecystitis?
A. Instruct the client to limit oral intake to three meals per day.
B. Instruct the client to drink fluids between meals, rather that with meals.
C. Instruct the client to limit the dietary intake of fat to 35% of the daily calorie intake.
D. Instruct the client to consume a low-fat diet consisting of smaller, more frequent meals.

ANS: D
Clients with acute cholecystitis are placed on small, frequent low-fat meals to decrease stimulation of the
gallbladder, thus decreasing pain, nausea, and vomiting.
8. What is the medication of choice for the client with acute cholecystitis who is
complaining of severe pain?
A. Morphine sulfate
B. Pentazocine (Talwin)
C. Meperidine hydrochloride (Demerol)
D. Trimethobenzamide hydrochloride (Tigan)

ANS: C
Meperidine is the usual drug of choice for pain associated with cholecystitis. Although meperidine can
cause spasms of the sphincter of Oddi, it does so to a lesser extent than morphine.

9. A client has just returned to the unit after having a traditional cholecystectomy with a
Jackson-Pratt (JP) drain put in place. The drainage from the JP drain appears serosanguineous in color.
What is the nurse’s best action?
A. Irrigate the drain.
B. Notify the physician.
C. Milk the drain tubing.
D. Document the finding as the only action.

ANS: D
The drainage from the JP drain initially appears serosanguineous in color. The drainage will appear bile-
colored within 24 hours.

10. A client undergone a traditional cholecystectomy with T-tube placement is preparing for
discharge. What statement made by the client indicates a need for further teaching regarding the care of the
T-tube ?
A. “I will inspect the T-tube drainage site for signs of infection.”
B. “I will clamp the T-tube for 1 to 2 hours before and after meals.”
C. “I will irrigate the T-tube with normal saline if the drainage appears too slow.”
D. “I will call my health care provider if I note a sudden increase in bile output.”

ANS: C
The client should be instructed to never irrigate the T-tube without first consulting with the physician.

11.What is the nurse’s best action for the client who has undergone a laparoscopic
cholecystectomy and complains of “free air pain.”
A. Ambulate the client.
B. Instruct the client to breathe deeply and cough.
C. Maintain the client on bedrest with his or her legs elevated.
D. Insert a rectal tube to facilitate the passage of flatus.

ANS: A
The client who has undergone a laparoscopic cholecystectomy may complain of free air pain because of the
retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote
absorption of the carbon dioxide.

12. Which of the following menus would be most appropriate for a client with cholelithiasis?
A. Two eggs, two slices of toast with margarine, and a glass of whole milk
B. Grilled cheese sandwich, steamed vegetables with butter, and coffee
C. Roast chicken, baked potato, and skim milk
D. Baked fish, steamed broccoli, and tea

ANS: C
Clients with cholelithiasis should avoid foods high in cholesterol, such as whole milk and butter, fried
foods, and gas-forming vegetables.

13. Which client is most at risk for the development of gallstones?


A. 22-year-old woman who is 1 month postpartum
B. 65-year-old woman after a liquid protein diet
C. 70-year-old man with peptic ulcer disease
D. 33-year-old man with type 2 diabetes

ANS: B
Liquid protein diets increase susceptibility to gallstones by releasing cholesterol from tissues, which is then
excreted as crystals in the bile.

14. A client with cholelithiasis has been prescribed chenodiol therapy. What clinical
manifestation indicates a side effect of this drug?
A. Pruritus
B. Diarrhea
C. Headaches
D. Photosensitivity

ANS: B
Diarrhea is a common side effect of chenodiol therapy.

15. A client with cholelithiasis and obstructive jaundice is experiencing severe pruritus for
which the health care provider has prescribed cholestyramine (Questran) for the client. What is the action
of this drug?
A. Cholestyramine blocks histamine, reducing the allergic response.
B. Cholestyramine inhibits the enzyme responsible for bile excretion.
C. Cholestyramine reduces the amount of bile stored in the gallbladder.
D. Cholestyramine binds with bile acids that are eventually excreted in the feces.

ANS: D
Cholestyramine binds with bile acids in the intestine, forming an insoluble compound excreted in the feces.

16. The nurse notes rebound tenderness in the client with peritoneal tenderness. What is the
correct term for this assessment?
A. Biliary colic
B. Murphy’s sign
C. Blumberg’s sign
D. Peristaltic waves

ANS: C
Rebound tenderness is termed Blumberg’s sign.

17. A client had a transhepatic biliary catheter placed 3 days ago. Which clinical
manifestation would indicate that the procedure was successful?
A. The client’s sclera remains icteric.
B. The client’s stools are brown in color.
C. The client’s urine is a dark amber color.
D. The client’s catheter has blood return on aspiration.

ANS: B
A transhepatic biliary catheter decompresses extrahepatic ducts to promote the flow of bile. When bile
flows normally, it reaches the large intestine where bile is converted to urobilinogen, coloring the stools
brown.

18. What alteration in laboratory data would suggest that lipolysis is occurring?
A. Hypocalcemia
B. Hyperkalemia
C. Hypernatremia
D. Hypoglycemia

ANS: A
In lipolysis, fatty acids are released and combine with ionized calcium to form a soaplike product. The
body cannot use bound calcium and the parathyroid gland is unable to compensate for the rapid loss of
ionized calcium; therefore, hypocalcemia occurs.

19. While performing an assessment of a client with acute pancreatitis, the nurse notes the
presence of Turner’s sign. What is the interpretation of this finding?
A. The client has pancreatic enzymes leaking into the skin.
B. The client is experiencing intra-abdominal bleeding.
C. The client has an intestinal obstruction.
D. The client has portal hypertension.

ANS: A
Turner’s sign is a gray-blue discoloration of the flanks caused by the leakage of pancreatic enzymes into the
cutaneous tissue.

20. What is Turner’s sign?


A. Contraction of the check on tapping the skin in front of the ear
B. The presence of uremic frost
C. Visible abdominal peristaltic waves.
D. A blue-gray discoloration of the flanks

ANS: D
Turner’s sign is a gray-blue discoloration of the flanks caused by the leakage of pancreatic enzymes into the
cutaneous tissue.

21. What laboratory marker would remain altered if a pancreatic pseudocyst is present?
A. Serum aspartate transaminase level
B. Serum amylase level
C. Serum bilirubin level
D. Serum lipase level

ANS: B
In the presence of pancreatic pseudocyst or abscess, serum amylase levels remain persistently elevated.

22. Which nursing measure would best reduce the discomfort and pain associated with acute
pancreatitis?
A. Placing the client in a semi-Fowler’s position, at 30 degrees
B. Maintaining NPO status during the acute period
C. Administering a PRN order for morphine sulfate
D. Giving small, frequent feedings as tolerated

ANS: B
Because abdominal pain is the key feature of acute pancreatitis, nursing measures to reduce GI activity and
decrease pancreatic enzyme production are used. Fasting helps rest the pancreas, so foods and fluids are
withheld during the acute period.

23. What is the most frequent cause of acute pancreatitis?


A. diabetes
B. Fat-laden diets
C. Alcoholism
D. Hypercholesteremia

ANS: C
Excessive alcohol intake is the most frequent cause of acute pancreatitis.

24. The client has undergone surgical placement of a pancreatic drainage tube to facilitate
drainage of a pancreatic abscess. Which nursing intervention would prevent a complication resulting from
this procedure?
A. Administration of pancreatic enzymes through the tube
B. Clamping the drainage tube every 2 hours
C. Placing the client in a right side-lying position
D. Application of a skin barrier around the drainage tube

ANS: D
The nurse assesses the skin around the drainage tube for redness or skin irritation that can be severe from
leakage of pancreatic enzymes. The nurse applies a skin barrier such as Stomahesive around the drainage
tube to prevent excoriation.

25. A client who had been discharged home with chronic pancreatitis reports that clay-
colored stools have increased in volume. What conclusion can the nurse draw from this report?
A. The client now requires home TPN feedings.
B. The client’s pancreatic insufficiency has progressed.
C. The client is recovering from malabsorption related to the disease.
D. The client should have a stool specimen sent for culture and sensitivity testing.
ANS: B
In chronic pancreatitis, an increase in stool volume with steatorrhea indicates a progression of pancreatic
insufficiency and a decrease in lipase production.

26. What statement made by a client receiving pancreatic enzyme replacement indicates a
need for further teaching?
A. “I can mix the enzyme powder in fruit juice.”
B. “I will wipe my lips after taking the enzyme preparation.”
C. “I will take the enzymes immediately after my meals.”
D. “I will not mix the enzyme powder in foods containing proteins.”

ANS: C
The enzyme preparation should be taken either before or with meals.

27. Which statement made by a client with chronic pancreatitis would indicate a need for
further teaching regarding dietary management of the disease?
A. “I will eat small, frequent meals.”
B. “I will avoid drinking caffeinated beverages.”
C. “I should eat foods high in fat and calories.”
D. “I should consume 4000 to 6000 calories/day.”

ANS: C
The client is instructed to consume a total of 4000 to 6000 calories/day of a diet high in carbohydrates and
protein, but low in fat. High-fat foods increase diarrhea.

28. Which clinical manifestation is often the presenting sign of pancreatic cancer?
A. Ascites
B. Fatigue
C. Jaundice
D. Abdominal pain

ANS: C
The symptoms of pancreatic cancer are insidious. The initial presenting sign is most often jaundice
resulting from gallbladder and liver involvement. Although jaundice may be the first presenting sign that
brings the client to seek health care, it is considered a late sign for the disease process.

29. Which of the following alterations in fluids and electrolytes would be expected in a client
with pancreatic cancer?
A. Fluid volume overload
B. Increased serum osmotic pressure
C. Elevated serum amylase and lipase levels
D. Increased serum sodium and decreased serum potassium levels

ANS: C
Although there are no specific laboratory tests for the diagnosis of pancreatic cancer, serum amylase and
lipase levels are elevated. The extent of the elevation depends on the amount of pancreatic damage.
30. While assessing the gastrointestinal drainage tube of a client who is 8 days postoperative
from a Whipple procedure, the nurse notes that the drainage from the tube has increased and there appears
to be frank blood in the tube. What is the nurse’s priority action?
A. Clamp the nasogastric tube.
B. Notify the health care provider.
C. Document the finding as the only action.
D. Irrigate the nasogastric tube with 20 mL of normal saline.

ANS: B
An increase in NG tube drainage accompanied by frank blood is an indication of disruption or leakage from
the anastomosis site. The health care provider should be notified immediately.

OTHER

1. Which of the following clients are at greatest risk for cholelithiasis? (Select all that
apply.)
A. Obese
B. Familial history
C. Age over 60 years
D. Type 1 diabetic
E. Alcoholic
F. Client with hemolytic anemia
G. Arthritic

ANS:
A, B, C, D, E, F
Rationale: The risks for cholelithiasis are many and include familial tendency, obesity, age, with people
over 60 at greater risk, and people with type 1 diabetes. The risk also includes those with alcohol abuse and
clients with hemolytic blood disorders.

Chapter 64: Interventions for Clients with Malnutrition and Obesity

MULTIPLE CHOICE

1. A client who follows a vegan diet has been diagnosed with megaloblastic anemia. What
additions to the diet does the client need?
A. A breakfast cereal fortified with vitamin B12
B. Additional iron-rich foods, such as spinach
C. Additional serving of legumes for calcium
D. A vitamin C–rich citrus fruit

ANS: A
In megaloblastic anemia, the client is deficient in vitamin B12.The client is advised to include a fortified
breakfast cereal, soy beverage, or meat alternative to the diet.
2. Which of the following clients is most at risk for malnutrition?
A. 80-year-old man residing in an assisted-living facility
B. 57-year-old woman with inflammatory bowel disease
C. 22-year-old man who plays several college sports
D. 44-year-old woman on a weight loss regimen

ANS: B
Although all these clients may be at risk for malnutrition, the client most at risk is the client with
inflammatory bowel disease, which impairs absorption of nutrients.

3. What body mass index (BMI) should older adults have?


A. Less than 21
B. Between 20 and 24
C. Between 24 and 27
D. Greater than 30

ANS: C
Older adults should have a BMI between 24 and 27.

4. Skin fold measurements are used to estimate which of the following?


A. Percentage of body fat
B. Degree of obesity
C. Body mass index
D. Degree of malnutrition

ANS: A
Skin fold measurements estimate body fat.

5. The client identifies a daily diet regularly consisting of two glasses of skim milk, 1 cup of
yogurt, two servings of meat or poultry, five servings of vegetables, three servings of fruit, and four
servings of bread, cereal, pasta, and/or rice. What suggestions for change should the nurse make for this
client to ensure that the client meets the Dietary Guidelines for Americans as an acceptable “guideline” for
dietary intake?
A. No suggestions are needed; the stated diet meets recommendations.
B. Increase bread, cereal, pasta, and/or rice.
C. Decrease vegetables.
D. Increase fruit.

ANS: B
The Dietary Guidelines for Americans recommend 6 to 11 servings each day from the bread, cereal, pasta,
and rice group.

6. The client asks the nurse, “How can I know how much 3 ounces of meat really is?”
Which of the following is correct?
A. It is the size of your fist.
B. It is the size of a matchbox.
C. It is the size of a deck of cards.
D. It is the size of a paperback book.

ANS: C
A 3-ounce serving of meat is the size of a deck of cards.

7. An older adult client has a serum albumin level of 2.9 g/dL. What interpretation should
the nurse make?
A. The client has no protein depletion.
B. The client has mild protein depletion.
C. The client has moderate protein depletion.
D. The client has severe protein depletion.

ANS: B
A serum albumin level of 2.8 to 3.5 g/dL is indicative of mild visceral protein depletion.

8. What medication might the nurse anticipate to stimulate the client’s appetite?
A. Diphenhydramine (Benadryl)
B. Methylprednisolone (Prednisone)
C. Triamcinolone hexacetonide (Aristocort)
D. Cyproheptadine hydrochloride (Periactin)

ANS: D
Cyproheptadine hydrochloride is an antihistamine with appetite-stimulating effects.

9. What specific adjustments in providing care should the nurse make when planning
interventions for the client who is malnourished?
A. Provide a quiet environment for meals.
B. Encourage the client to have friends visit during meal times.
C. Plan meals to be large and contain as many calories as possible.
D. Be certain that the client has emptied his or her bladder before meals.

ANS: A
The client may take a long time to eat even small amounts of food. Meal interruptions for any reason
decrease the client’s food intake. A quiet environment conducive to eating should be provided.

10. The family of a client receiving total enteral nutrition by nasoenteric tube asks why this
method is being used, because the client is capable of chewing and swallowing. What is the nurse’s best
response?
A. “This method of feeding takes far less time.”
B. “The surgeon always orders these feedings before surgery.”
C. “This type of feeding will help increase nutritional status before surgery.”
D. “There is no need for the client to spend so much energy on chewing and swallowing food.”

ANS: C
The decision to use total enteral nutrition by nasoenteric tube is made to provide short-term delivery of
nutrition. Increasing nutritional intake and improving nutritional status before surgery is one example of
using this type of nutrition to benefit the client.

11. What test should be performed to confirm tube placement of a nasoenteric feeding tube
before the start of feedings?
A. An x-ray study
B. Auscultation of the abdomen
C. Assessment of stomach content pH
D. Assessment of residual stomach contents

ANS: A
An x-ray study is the most accurate confirmation method for ascertaining the exact placement of an enteral
feeding tube and should always be done on initial tube insertion. Auscultation is completely unreliable.
Residual assessment is difficult to obtain with small-bore feeding tubes. The pH of the fluid returned is
more reliable than auscultation or residual assessment but not as certain as x-ray confirmation.

12. What nursing intervention will help prevent a client’s feeding tube from becoming
clogged?
A. Administer medications in a liquid rather than crushed state
B. Flush the feeding tube with an acidic liquid, such as cranberry juice.
C. Flush the feeding tube with water before each intermittent tube feeding.
D. Do not flush the tube for continuous feeding; interruptions cause clogging.

ANS: A
The administration of liquid medications rather than crushed medications, which do not always dissolve
well, will help prevent clogging. The tube should be flushed before and after each intermittent feeding and
every 4 hours for a continuous feeding. Never use cranberry juice for clearing a clogged tube.

13. Which of the following clients receiving enteric feedings through a nasoenteric tube are
most at risk for the potential of increased plasma osmolarity?
A. 50-year-old client receiving an isotonic enteral feeding product
B. 75-year-old unconscious client receiving a hyperosmolar enteral feeding product
C. 38-year-old client receiving a hyperosmolar enteral feeding product, who also eats and drinks PRN
D. 70-year-old client with an IV of D5W infusing at 125 mL/hr, who is also receiving a hyperosmolar
enteral feeding product

ANS: B
Clients at risk for increased plasma osmolarity are older adults, those receiving hyperosmolar enteral
feeding products, and those who are unconscious, unable to respond to the thirst reflex, or on fluid
restrictions.

14. The nurse is caring for a client receiving total parenteral nutrition (TPN) at 125 mL/hr.
The client complains of excessive urination. The client’s finger stick reveals an elevated blood sugar level.
The nurse realizes the client is at risk for which of the following?
A. Rebound hypoglycemia
B. Hypovolemic shock
C. Hyperkalemia
D. Hypernatremia
ANS: B
When TPN is administered rapidly, water shifts into the plasma. Expansion of plasma volume in the
presence of hyperglycemia predisposes the client to osmotic diuresis, dehydration, and hypovolemic shock.

15. What medication would predispose the client to obesity?


A. Lovastatin
B. Metoprolol
C. Lanoxin (Digoxin)
D. Dexamethasone

ANS: D
Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid metabolism,
predisposing the client to obesity when taking these drugs on a chronic basis. Blood glucose and blood lipid
levels are elevated. In addition, corticosteroids increase the client’s appetite.

16. A client is being treated for obesity with orlistat (Xenical). What statement made by the
client indicates an understanding of the medication regimen?
A. “This medication will make me feel full.”
B. “I may have loose stools with this medication.”
C. “This medication will increase my metabolic rate.”
D. “This medication will turn my urine a bright yellow color.”

ANS: B
Orlistat (Xenical) inhibits lipase and leads to partial hydrolysis of triglycerides. Fats are only partially
digested and absorbed and are excreted in the feces. The client may experience nausea, cramps, and loose
stools.

17. What dietary discharge instructions should be given to the client who has undergone
gastroplasty?
A. “Your diet will be limited to liquids or puréed foods for 6 weeks.”
B. “You will be placed on a low-protein diet for the first 2 months after surgery.”
C. “You will be gradually progressed to eating three meals per day during your hospitalization.”
D. “You will need to continue taking the anorectic drug prescribed for you until your stomach
shrinks.”

ANS: A
The client who has undergone a gastroplasty should progress the diet from liquids to puréed foods and
finally to solids to prevent overdistention of the pouch.

18. The client who has undergone gastroplasty has an NG tube. Which of the following
nursing interventions regarding care of the tube takes priority in this client?
A. Closely monitor the tube for patency.
B. Never reposition the tube.
C. Closely monitory tube output.
D. Auscultate for bowel sounds frequently.

ANS: B
Never reposition the tube because its movement can disrupt the suture line. All other choices are important
but do not take priority.

OTHER

1. Common complications of severe malnutrition include which of the following? (Select all
that apply.)
A. Cachexia
B. Lethargy
C. Intolerance to cold
D. Edema
E. Poor wound healing
F. Dry skin
G. Steatorrhea

ANS:
A, B, C, D, E, F
Rationale: Complications of severe malnutrition include cachexia, lethargy, intolerance to cold, edema,
poor wound healing, and dry skin.

Chapter 68: Interventions for Clients with Diabetes Mellitus

MULTIPLE CHOICE

1. Which statement regarding diabetes mellitus is true?


A. Diabetes increases the risk for development of epilepsy.
B. The cure for diabetes is the administration of insulin.
C. Diabetes increases the risk for development of cardiovascular disease.
D. Carbohydrate metabolism is disturbed in diabetes, but protein and lipid metabolism are normal.

ANS: C
Diabetes mellitus is a major risk factor for morbidity and mortality caused by coronary artery disease,
cerebrovascular disease, and peripheral vascular disease.

2. The client diabetic client asks the nurse why it is necessary to maintain blood glucose
levels no lower than about 74 mg/dL. What is the nurse’s best response?
A. “Glucose is the only fuel form used by body cells to produce energy needed for physiologic
activity.”
B. “The central nervous system, which cannot store glucose, requires a continuous supply of glucose
for fuel.”
C. “Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP.”
D. “The presence of glucose in the blood counteracts the formation of lactic acid and prevents
acidosis.”

ANS: B
Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the
body's circulation is needed to meet the fuel demands of the central nervous system.

3. How does glucagon assist in maintaining blood glucose levels?


A. Glucagon enhances the activity of insulin, restoring blood glucose levels to normal more quickly
after a high-calorie meal.
B. Glucagon is a storage form of glucose and can be broken down for energy when blood glucose
levels are low.
C. Glucagon converts the excess glucose into glycogen, lowering blood glucose levels in times of
excess.
D. Glucagon prevents hypoglycemia by promoting glucose release from liver storage sites.

ANS: D
Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas when blood glucose
levels are low. The actions of glycogen that raise blood glucose levels include stimulating the liver to break
down glycogen (glycogenolysis) and forming new glucose from protein breakdown (gluconeogenesis).

4. What is the physiologic basis for the polyuria manifested by individuals with untreated
diabetes mellitus?
A. Inadequate secretion of antidiuretic hormone (ADH)
B. Early-stage renal failure causing a loss of urine concentrating capacity
C. Chronic stimulation of the detrusor muscle by the ketone bodies in the urine
D. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia

ANS: D
Polyuria results from an osmotic diuresis caused by excess excretion of glucose in the urine.

5. What is the basic underlying pathology of diabetes mellitus?


A. A disruption of the cellular glycolytic pathway
B. An inability of the liver to catabolize glycogen
C. A failure to synthesize and/or utilize insulin
D. An inhibition of the conversion of protein to amino acids

ANS: C
The lack of insulin in diabetes, either from a lack of insulin secretion or from insulin receptor pathology,
prevents insulin-sensitive cells from using glucose as an energy source.

6. Which assessment finding in the client with diabetes mellitus indicates that the disease is
damaging the kidneys?
A. The presence of ketone bodies in the urine during acidosis
B. The presence of glucose in the urine during hyperglycemia
C. The presence of protein in the urine during a random urinalysis
D. The presence of white blood cells in the urine during a random urinalysis

ANS: C
Urine should not contain protein, and the presence of proteinuria in a diabetic marks the beginning of renal
problems known as diabetic nephropathy, which progresses eventually to end-stage renal disease.
Chronically elevated blood glucose levels cause renal hypertension and excess kidney perfusion with
leakage from the renal vasculature. The excess leakiness allows larger substances, such as proteins, to be
filtered into the urine.
7. The client is a 28-year-old man newly diagnosed with type 1 diabetes mellitus. He wears
glasses for myopia and asks the nurse how frequently he should see his ophthalmologist now. What is the
nurse’s best answer?
A. “At your age, you do not need to change your usual patterns for visiting the ophthalmologist.”
B. “See your ophthalmologist whenever you have a vision problem and yearly after you are 40 years
old.”
C. “Your vision will change more quickly now, and you should see the ophthalmologist whenever
you find that your glasses are not strong enough to allow you to read comfortably.”
D. “The disease increases your risk for cataracts, glaucoma, and retinal blood vessel changes, so you
should see the ophthalmologist yearly, even when you do not have a new vision problem.”

ANS: D
Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless
of age, should be examined by an ophthalmologist (rather than an optometrist or an optician) at diagnosis
and at least yearly thereafter.

8. While assessing the client who has had diabetes for 15 years, the nurse notes that the
client has decreased tactile sensation in both feet. What is the nurse’s best first action?
A. Document the finding as the only action.
B. Test sensory perception in the client's hands.
C. Examine the client's feet for signs of injury.
D. Notify the physician.

ANS: C
Diabetic neuropathy is common when the disease is long-standing. It cannot be reversed and the client is at
great risk for injury in any area with decreased sensation, because he or she is less able to feel injurious
events.

9. The 30-year-old woman whose father has type 1 diabetes mellitus asks the nurse what her
chances are of developing diabetes because of her father's disease. What is the nurse’s best response?
A. “You have a greater susceptibility for developing the disease, with a 1 in 20 to a 1 in 50 chance.”
B. “Your risk is the same as the general population, because there is no genetic risk for development
of type 1 diabetes.”
C. “Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore, the risk for becoming
diabetic is 50%.”
D. “Because you are a woman and your father is the parent with the diabetes, your risk is not
increased for eventual development of the disease; however, your brothers will become diabetic.”

ANS: A
Although type 1 diabetes does not follow any specific genetic pattern of inheritance, clients who have one
parent with type 1 diabetes are at an increased risk for development. The incidence of diabetes in people
who have a parent with type 1 diabetes ranges between 1 in 20 to 1 in 50, compared with 1 in 400 to 1 in
1000 in people who do not have one parent with type 1 diabetes.

10. Which action should the nurse teach the diabetic client as being most beneficial in
delaying the onset of microvascular and macrovascular complications?
A. Controlling hyperglycemia
B. Preventing hypoglycemia
C. Restricting fluid intake
D. Preventing ketosis

ANS: A
The Diabetes Control and Complications Trial, a prospective study involving 29 medical centers and more
than 1400 people with type 1 diabetes, provides convincing evidence that hyperglycemia is a critical factor
in the pathogenesis of long-term diabetic complications.

11. With which client should the nurse be alert for undiagnosed diabetes mellitus?
A. 25-year-old white male
B. 45-year-old African American man
C. 25-year-old African American woman
D. 45-year-old Native American woman

ANS: D
The highest incidence of diabetes mellitus in the United States is among Native Americans. The incidence
of diabetes increases in all races and ethnic groups with age.

12. The 30-year-old woman whose mother has type 2 diabetes mellitus asks the nurse what
her chances are of developing diabetes because of her mother's disease. What is the nurse’s best response?
A. “You have a greater susceptibility for developing the disease, with a 1 in 20 to a 1 in 50 chance.”
B. “Your risk is the same as the general population, because there is no genetic risk for development
of type 2 diabetes.”
C. “Type 2 diabetes is inherited in an autosomal dominant pattern. Therefore, your risk for becoming
diabetic is 50%.”
D. “Children of people with type 2 diabetes have a 15% chance of developing the disease, but
environmental factors, such as obesity, also influence your risk.”

ANS: D
Type 2 diabetes shows a stronger genetic predisposition or tendency than does type 1. The risk for people
who have one parent with type 2 diabetes is at least 15% for actually developing the disease and 30% for
having impaired glucose tolerance. This type of diabetes is greatly influenced by other modifiable
variables, such as obesity and a sedentary lifestyle.

13. Which intervention for self-monitoring of blood glucose levels should the nurse teach the
client with diabetes to prevent bloodborne infections?
A. “Wash your hands before beginning the test.”
B. “Do not share your monitoring equipment.”
C. “Blot excess blood from the strip.”
D. “Use gloves during monitoring.”

ANS: B
Small particles of blood can adhere to the monitoring device and infection can be transported from one user
to another.

14. The client newly diagnosed with type 1 diabetes mellitus has just learned to measure
urine ketone bodies. She asks the nurse when this should be done. What is the nurse’s best response?
A. “Daily, just before you take your insulin.”
B. “Whenever you test your blood for glucose.”
C. “Whenever you are ill or your blood sugar is consistently higher than 300 mg/dL.”
D. “Whenever you participate in vigorous exercise or experience a change in your daily activity
level.”

ANS: C
The presence of ketone bodies in the urine may indicate impending ketoacidosis. Daily testing is not
necessary. Urine should be tested for ketone bodies whenever the client is acutely ill, under stress,
pregnant, or participating in a weight reduction program, or has symptoms of ketoacidosis (nausea,
vomiting, and abdominal pain).

15. What precaution should the nurse teach the client who has type 2 diabetes and is
prescribed to take an oral sulfonylurea agent to maintain control of blood glucose levels?
A. “Change positions slowly.”
B. “Avoid taking nonsteroidal anti-inflammatory agents.”
C. “Do not skip the medication, even if you are unable to eat.”
D. “Discontinue the medication if you develop an infection.”

ANS: B
Nonsteroidal anti-inflammatory agents potentiate the hypoglycemic effects of sulfonylurea agents.

16. With which therapy for diabetes mellitus is the client not at risk for hypoglycemia?
A. Regular insulin
B. Lente insulin
C. Biguanides
D. Sulfonylureas

ANS: C
The biguanides do not lower blood glucose levels by affecting insulin secretion, but rather increase the
sensitivity of the insulin receptors to the naturally occurring insulin. Thus, these drugs do not cause
hypoglycemia (although clients can become hypoglycemic by prolonged fasting).

17. The client with type 2 diabetes had been taking the oral antidiabetic agents glyburide and
metformin. These medications have been discontinued and he has now been prescribed to take Glucovance.
He asks why he only needs one medication. What is the nurse’s best response?
A. “Glucovance is more effective than glyburide and metformin.”
B. “Glucovance contains a combination of glyburide and metformin.”
C. “Glucovance is a new oral insulin and replaces all other oral antidiabetic agents.”
D. “Your diabetes is improving and you now only need one drug for blood glucose control.”

ANS: B
Glucovance is composed of glyburide and metformin in commonly used doses to increase the convenience
of antidiabetic therapy with glyburide and metformin.

18. The client with type 2 diabetes is prescribed to take the antidiabetic agent nateglinide
(Starlix). Which statements made by the client indicates correct understanding of this therapy?
A. “I'll take this medicine with my meals.”
B. “I'll take this medicine 15 minutes before I eat.”
C. “I'll take this medicine just before I go to bed.”
D. “I'll take this medicine as soon as I wake up in the morning.”

ANS: B
Nateglinide is a D-phenylalanine derivative that causes the beta cells of the pancreas to undergo
depolarization and release a small amount of preformed insulin. The peak action occurs about 20 minutes
after ingestion. To have the best action and prevent hypoglycemia, clients are instructed to take the drug
about 15 minutes before eating.

19. The client who has been taking the oral antidiabetic agent pioglitazone (Actos) for 6
months reports to the nurse that his urine is darker than it used to be. What is the nurse’s best action?
A. Notify the physician.
B. Document the report as the only action.
C. Instruct the client to increase his water intake.
D. Test a sample of urine for the presence of occult blood.

ANS: A
The “glitazone” drugs, including pioglitazone, have been reported to affect liver function, and there have
been some cases of liver failure. Dark urine is one indicator of liver impairment because bilirubin increases
in the blood and is excreted in the urine.

20. The client with type 1 diabetes mellitus is switching from an animal-source regular
insulin to a synthetically derived human regular insulin. Which precaution should the nurse explain to this
client?
A. “Human insulin should only be administered in the umbilical area.”
B. “Do not mix human regular insulin with any other type of insulin.”
C. “Adjustments in insulin timing may be needed with the human regular insulin.”
D. “You may notice the need to increase the dose to achieve the same level of glucose control.”

ANS: C
Human insulin has a more rapid onset of action, a shorter time to peak action, and a shorter duration of
action than the same insulin type derived from animal sources.

21. The client with diabetes who is just starting on insulin therapy wants to know why more
than one injection of insulin each day will be required. What is the nurse’s best response?
A. “You need to start with multiple injections until you become more proficient at self-injection.”
B. “A single dose of insulin each day would not match your blood insulin levels and your food intake
patterns closely enough.”
C. “A regimen of a single dose of insulin injected each day would require that you could eat no more
than one meal each day.”
D. “A single dose of insulin would be too large to be absorbed predictably, so you would be in danger
of unexpected insulin shock.”

ANS: B
Even when a single injection of insulin contains a combined dose of different-acting insulins, the timing of
the actions and the timing of food intake may not match well enough to prevent wide variation in blood
glucose levels.
22. Which statement made by a client whom the nurse is teaching how to self-inject insulin
reflects a need for clarification of injection site selection and rotation?
A. “The abdominal site is best because it is closest to the pancreas.”
B. “I can reach my thigh the best, so I will use different areas of the same thigh.”
C. “By rotating the sites within one area, my chances of having tissue increases or decreases is less.”
D. “If I change injection sites from the thigh to the arm, the rate of absorption will be different.”

ANS: A
The abdominal site has the fastest rate of absorption because of the blood vessels in the area and not
because of its proximity to the pancreas.

23. The client who has used insulin for diabetes control for 20 years has a spongy swelling at
the site used most frequently for insulin injection. What is the nurse’s best action?
A. Apply ice to this area.
B. Document the finding as the only action.
C. Assess the client for other signs of cellulitis.
D. Instruct the client to use a different site for insulin injection.

ANS: D
The client has hypertrophic lipodystrophy as a result of repeated injections at the same site. Avoiding this
site for an extended period of time allows the dystrophic changes to regress or at least not to become worse.

24. The client who has diabetes is prescribed to take insulin glargine once daily and regular
insulin four times daily. The first dose of regular insulin occurs at the same time of day as the insulin
glargine dose. How should the nurse teach the client to take these two medications?
A. “Draw up and inject the insulin glargine first and then draw up and inject the dose of regular
insulin.”
B. “Draw up and inject the insulin glargine first, wait 1 hour, and then draw up and inject the dose of
regular insulin.”
C. “First draw up the dose of regular insulin, and then draw up the dose of insulin glargine in the
same syringe, mix, and inject the two insulins together.”
D. “First draw up the dose of insulin glargine, and then draw up the dose of regular insulin in the
same syringe, mix, and inject the two insulins together.”

ANS: A
Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an
unpredictable alteration in the onset of action and time to peak action.

25. The client on an intensified insulin regimen consistently has a fasting blood glucose
between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c
level of 5.5%. What is the nurse’s interpretation of these findings?
A. The client is at increased risk for developing hypoglycemia.
B. The client is at increased risk for developing hyperglycemia.
C. The client is demonstrating signs of insulin resistance.
D. The client is demonstrating good control of blood glucose.

ANS: D
The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen
(fasting blood glucose 60 to 120 mg/dL; postprandial blood glucose less than 200 mg/dL; hemoglobin A1c
4% to 6%).

26. The client with diabetes is visually impaired and wants to know if syringes can be
prefilled and stored for use later. What is the nurse’s best response?
A. “Yes, prefilled syringes can be stored for up to 3 weeks in the refrigerator in a vertical position
with the needle pointing up.”
B. “Yes, prefilled syringes can be stored for up to 3 weeks in the refrigerator, placed in a horizontal
position.”
C. “Insulin reacts with plastic, so prefilled syringes must be made of glass.”
D. “No, insulin cannot be stored for any length of time outside of the container.”

ANS: A
Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled
syringes are stable for up to 3 weeks and should be stored in the vertical position with the needle pointing
up to prevent suspended insulin particles from clogging the needle.

27. What intervention should the nurse teach the client with diabetes who uses an insulin
infusion pump to prevent the complication of infection?
A. “Test your urine daily for the presence of ketone bodies.”
B. “Use buffered insulin to prevent crystal formation.”
C. “Keep the insulin frozen until you fill the pump.”
D. “Change the needle every 3 days.”

ANS: D
Having the same needle remain in place through the skin for longer than 3 days drastically increases the
risk for infection within or through the delivery system.

28. Which statement made by the client newly diagnosed with type 2 diabetes mellitus
indicates a need for clarification regarding diet therapy?
A. “I should increase my intake of vegetables with moderate to high amounts of dietary fiber.”
B. “My intake of saturated fats should be no more than 10% of my total calorie intake.”
C. “I should try to keep my diet free from carbohydrates.”
D. “My intake of plain water each day is not restricted.”

ANS: C
Carbohydrates are an extremely important source of energy and should compose at least 50% to 60% of the
diabetic person's total caloric intake.

29. The client newly diagnosed with type 2 diabetes tells the nurse that since he has increased
his intake of fiber, he is having loose stools, flatulence, and abdominal cramping. What is the nurse’s best
response?
A. “Decrease your intake of water and other fluids.”
B. “Decrease your intake of fiber now and gradually add high-fiber foods back into your diet.”
C. “You must have allergies to high-fiber foods and will need to avoid them in the future.”
D. “Taking an antacid 1 hour before meals or 2 hours after meals should reduce the intensity of your
bowel problems.”

ANS: B
Many people experience these side effects when first increasing dietary fiber. Gradually incorporating high-
fiber foods into the diet can minimize abdominal cramping, discomfort, loose stools, and flatulence.

30. For which situation should the nurse suggest the pen-type injector insulin delivery
system?
A. The client who is confused and must rely on another person for insulin injections
B. The client using intensive therapy who must use insulin frequently in small doses
C. The client who is visually impaired and cannot accurately draw up insulin
D. The client who has frequent episodes of hypoglycemia

ANS: B
The pen-type injector allows greater accuracy with small doses, especially doses lower than 5 units. They
are not recommended for people who have visual or neurologic impairments.

31. What intervention should the nurse suggest to the diabetic client who self-injects insulin
to prevent or limit local irritation at the injection site?
A. “Do not reuse needles.”
B. “Massage the site for 1 full minute after injection.”
C. “Try to make the injection deep enough to enter muscle.”
D. “Allow the insulin to warm to room temperature before injection.”

ANS: D
Cold insulin directly from the refrigerator is the most common cause of irritation (not infection) at the
insulin injection site.

32. Which nutritional group should the nurse teach the diabetic client with normal renal
function to rigidly control to reduce the complications of diabetes?
A. Fats
B. Fiber
C. Proteins
D. Carbohydrates

ANS: A
Diabetes causes abnormalities in fat metabolism that lead to hyperlipidemia. The high lipid levels promote
atherosclerosis and many pathologic consequences of vascular insufficiency. Although fats are essential and
the diet of a person with diabetes needs to contain some fat, total fats should be limited to 15% to 20% of
the total daily caloric intake.

33. The 45-year-old diabetic client has proliferative retinopathy, nephropathy, and peripheral
neuropathy. What should the nurse teach this client about exercise?
A. “The type of exercise that would most efficiently help you to lose weight, decrease insulin
requirements, and maintain cardiovascular health would be jogging for 20 minutes 4 to 7 days each week.”
B. “Considering the complications you already have, vigorous exercise for an hour each day is
needed to prevent progression of disease.”
C. “Considering the complications you already have, you should avoid engaging in any form of
exercise.”
D. “Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you.”
ANS: D
Exercise is not contraindicated for this client, although modifications are necessary based on existing
pathology to prevent further injury. A person with nephropathy and peripheral neuropathy should avoid
jogging or any activity that increases blood pressure or jars kidneys and joints. Swimming, or, if the client
does not know how to swim, dancing or doing exercises in water, provides support for joints and muscles,
greatly reducing the risk for injury while increasing the uptake of glucose and promoting cardiovascular
health.

34. Which clinical manifestation in a client with uncontrolled diabetes mellitus should the
nurse expect as a result of the presence of ketoacid in the blood?
A. Increased rate and depth of respiration
B. Extremity tremors followed by seizure activity
C. Oral temperature of 102° F (38.9° C)
D. Severe orthostatic hypotension

ANS: A
Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer
the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in
an attempt to excrete more acids by exhalation.

35. Which arterial blood gas values indicate to the nurse that the client is experiencing
ketoacidosis?
A. pH 7.38, HCO3– 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
B. pH 7.28, HCO3– 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
C. pH 7.48, HCO3– 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg
D. pH 7.28, HCO3– 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B
When the lungs can no longer offset the acidosis, the pH decreases below normal. The arterial blood gases
show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory
alkalosis with decreased carbon dioxide levels.

36. What is the priority intervention for the client having Kussmaul respirations as a result of
diabetic ketoacidosis?
A. Administration of oxygen by mask or nasal cannula
B. Intravenous administration of 10% glucose
C. Implementation of seizure precautions
D. Administration of intravenous insulin

ANS: D
The rapid, deep respiratory efforts of Kussmaul respiration is the body's attempt to reduce the acids
produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and who does not also
have a respiratory impairment does not need additional oxygen. Only the administration of insulin will
reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat.

37. The client tells the nurse that he enjoys having a glass of wine on Saturdays when dining
out with friends. He asks if having type 1 diabetes will prohibit him from this activity. What is the nurse’s
best response?
A. “Insulin activity is dramatically reduced under the influence of alcohol and drinking even one
glass of wine will increase your insulin requirements.”
B. “Diabetics have decreased kidney function and should avoid ingesting alcohol in all forms at all
times.”
C. “You shouldn't drink any alcohol because it is likely to increase your sense of hunger and make
you overeat.”
D. “One glass of wine can be ingested with a meal and is counted as two fat exchanges.”

ANS: D
Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when
diabetes is well controlled. When using insulin, two alcoholic beverages for men and one for women can be
ingested with and in addition to the normal meal plan. Because alcohol can induce hypoglycemia, it should
be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when
caloric intake is calculated.

38. Which nutritional problem should the nurse be more alert for in older adult clients with
diabetes mellitus?
A. Obesity
B. Malnutrition
C. Alcoholism
D. Hyperglycemia

ANS: B
Older adults are more at risk for developing malnutrition as a result of multiple factors. Inadequate income,
poor dentition, decreased cognition, decreased motor ability, depression, and lack of understanding about
what foods constitute an adequate diet all contribute to an increased risk for malnutrition among all older
adult clients, including those with diabetes mellitus.

39. Which action should the nurse suggest to reduce insulin needs in the client with diabetes
mellitus?
A. Reducing intake of water and other liquids to no more than 2 L/day
B. Eating animal organ meats high in insulin
C. Taking two 1-hour naps daily
D. Walking 1 mile each day

ANS: D
Moderate exercise, such as walking, helps regulate blood glucose levels on a daily basis and results in
lowered insulin requirements for clients with type 1 diabetes.

40. The client getting ready to engage in a 30-minute, moderate-intensity exercise program
performs a self-assessment. Which data indicate that exercise should be avoided at this time?
A. Ketone bodies in the urine
B. Blood sugar level of 155 mg/dL
C. Pulse rate of 66 beats/min
D. Weight 1 pound higher than the week before

ANS: A
The presence of ketone bodies in the urine is a contraindication to exercise because it indicates that the
amount of insulin available is inadequate to promote intracellular glucose transport and utilization. Exercise
would lead to further elevations in blood glucose levels.
41. Which action should the nurse suggest to the client who has been having difficulty with
hypoglycemia to decrease the rate of insulin absorption from the injection site?
A. Massaging the injection site
B. Exercising within 1 hour of insulin injection
C. Injecting into muscle rather than subcutaneous tissue
D. Using refrigerated insulin without warming it to room temperature

ANS: D
Massaging the injection site, exercising (especially moving the extremity that was injected), and injecting
into muscle all increase the rate of absorption. Using cold insulin decreases the rate of absorption and
increases the chance of developing inflammatory responses at the site of injection.

42. Two months after a simultaneous pancreas-kidney transplant (SPK), the client returns and
is diagnosed as being in an acute rejection episode. The client makes this statement to the nurse: “I was
doing so well with my new organs, and the thought of having to go back to living on hemodialysis and
taking insulin is so depressing.” What is the nurse’s best response?
A. “You should have followed your drug regimen better.”
B. “You should be glad that at least dialysis treatment is an option for you. Remember that people
whose liver transplants are rejected have no other options.”
C. “You should keep in mind that one acute rejection episode does not mean that you will lose the
new organs. Usually, these episodes can be reversed with the right treatment.”
D. “You should remember that finding a donor for a new kidney or pancreas is the easiest transplant
option. Our center is high on the list for obtaining organs for transplant from the national registry.”

ANS: C
An episode of acute rejection does not automatically mean that the client will lose the transplant.
Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow
the graft to be maintained.

43. Which statement made by the client getting ready for discharge after a pancreas
transplant indicates a need for clarification of the post-transplantation drug regimen?
A. “If I develop an infection, I should stop taking my corticosteroid.”
B. “If I have pain over the area of the transplant, I will call the transplantation team immediately.”
C. “I should avoid people who are ill or who have an infection because I am somewhat
immunosuppressed now.”
D. “I should mix my cyclosporine exactly the way I was taught, because it won't work as well if I
change the routine.”

ANS: A
Immunosuppressive agents should not be stopped without the consultation of the transplantation physician,
even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ.

44. Which laboratory value indicates inadequate functioning of a transplanted pancreas?


A. Total white blood cell count <5000/mm3
B. 50% decrease in urine amylase level
C. Blood urea nitrogen >30 mg/dL
D. Elevated bilirubin level

ANS: B
Most pancreas transplants are anastomosed to the bladder and drain pancreatic enzymes into the urine.
When the pancreas is rejected or functioning inadequately, the level of pancreatic enzymes in the urine
decreases by 25% or more.

45. Three hours after surgery, the nurse note that the breath of the client who is a type 1
diabetic has a “fruity” odor. What is the nurse’s best first action?
A. Document the finding as the only action.
B. Increase the IV fluid flow rate.
C. Test the urine for ketone bodies.
D. Perform oral care.

ANS: C
The stress of surgery increases the action of counterregulatory hormones and suppresses the action of
insulin, predisposing the client to ketoacidosis and metabolic acidosis.

46. The client with type 1 diabetes has a blood glucose level of 160 mg/dL on arrival at the
operating room. What is the nurse’s best action?
A. Document the finding as the only action.
B. Administer regular insulin.
C. Cancel the surgery.
D. Notify the physician.

ANS: A
Clients who have type 1 diabetes and are having surgery have been found to have fewer complications,
lower rates of infection, and better wound healing if blood glucose levels are maintained between 120
mg/dL and 200 mg/dL throughout the perioperative period.

47. The diabetic client has severe peripheral neuropathy, resulting in numbness and reduced
sensation. Which intervention should the nurse teach the client to prevent injury as a result of this
complication?
A. “Examine your feet daily.”
B. “Rotate your insulin injection sites.”
C. “Wear white socks instead of colored socks.”
D. “Use a bath thermometer to test water temperature.”

ANS: D
Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot.
Examining the feet daily does not prevent injury.

48. A client who has long-standing diabetes mellitus and severe, burning pain in the feet and
hands as a result of peripheral neuropathy asks the nurse why an antidepressant has been prescribed. What
is the nurse’s best response?
A. “Many people experiencing chronic pain become depressed.”
B. “The antidepressants may counteract the chemicals causing your pain.”
C. “You are less likely to become addicted from using antidepressants than you are from using other
types of pain killers.”
D. “The antidepressants also have strong anti-inflammatory properties and can reduce the pain you
have from inflammation.”
ANS: B
Much of the pain and discomfort associated with peripheral neuropathy is caused by changes in
neurotransmitter release at nerve synapses, especially serotonin. Small doses of antidepressants can inhibit
serotonin uptake and provide some degree of analgesia.

49. Which change in clinical manifestations in a client with long-standing diabetes mellitus
alerts the nurse to the possibility of renal dysfunction?
A. Loss of tactile perception
B. The presence of glucose in the urine
C. The presence of ketone bodies in the urine
D. A sustained increase in blood pressure from 130/84 to 150/100

ANS: D
Hypertension is both a cause of renal dysfunction and a result of renal dysfunction.

50. For the diabetic client with microalbuminuria, what dietary modification should the nurse
suggest?
A. Decreased percentage of total calories derived from carbohydrates
B. Decreased percentage of total calories derived from proteins
C. Decreased percentage of total calories derived from fats
D. Decreased total caloric intake

ANS: B
Restriction of dietary protein to 0.8 g/kg body weight/day is recommended for clients with
microalbuminuria to retard progression to renal failure.

51. Which statement made by the diabetic client who has a urinary tract infection indicates
correct understanding regarding antibiotic therapy?
A. “If my temperature is normal for 3 days in a row, the infection is gone and I can stop taking my
medicine.”
B. “If my temperature goes above 100° F (37.8° C) for 2 days, I should take twice as much
medicine.”
C. “Even if I feel completely well, I should take the medication until it is gone.”
D. “When my urine no longer burns, I will no longer need to take the antibiotics.”

ANS: C
Antibiotic therapy is most effective when the client takes the prescribed medication for the entire course
and not just when symptoms are present.

52. The home care nurse administers ½ cup of orange juice to the client with diabetes who is
experiencing symptoms of a mild hypoglycemic episode. The client's clinical manifestations have not
changed 5 minutes later. What is the nurse’s best next action?
A. Administer an additional ½ cup of orange juice.
B. Document the finding as the only action.
C. Administer 10 units of regular insulin.
D. Notify the physician.
ANS: A
For mild hypoglycemic manifestations, if the symptoms do not resolve immediately, repeat the treatment.

53. The nurse is administering intramuscular glucagon to a diabetic client who is


hypoglycemic and unable to swallow. Which precaution should the nurse institute for complications or
responses to this therapy?
A. Apply pressure to the injection site for 5 minutes.
B. Position the client on his or her side.
C. Have a padded tongue blade available.
D. Elevate the head of the bed.

ANS: B
Glucagon administration often induces vomiting, increasing the client's risk for aspiration.

54. The nurse is rapidly infusing insulin to a client with extreme hyperglycemia. Which
electrolyte abnormality indicates that the infusion is too rapid?
A. Serum chloride level of 90 mmol/L
B. Serum calcium level of 8.0 mg/dL
C. Serum sodium level of 132 mmol/L
D. Serum potassium level of 2.5 mmol/L

ANS: D
Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the
extracellular fluid into the intracellular fluid and resulting in hypokalemia.

55. What instruction should the nurse emphasize when teaching the diabetic client about how
to alter diabetes management during a period of illness that includes nausea and vomiting.
A. “Continue your prescribed exercise regimen.”
B. “Avoid eating or drinking to reduce vomiting.”
C. “Do not use insulin or take your oral antidiabetic agent.”
D. “Monitor your blood glucose levels at least every 4 hours.”

ANS: D
Treatment decisions and alterations will be made on the basis of blood glucose levels and the presence of
ketone bodies in the urine.

56. Why is ketosis rare in clients with type 2 diabetes, even when blood glucose levels are
very high (higher than 900 mg/dL)?
A. Ketosis is less prevalent among obese adults.
B. People with type 2 diabetes have normal lipid metabolism.
C. There is enough insulin produced by type 2 diabetes to prevent fat catabolism but not enough to
prevent hyperglycemia.
D. Oral antidiabetic agents do not promote the breakdown of fat for fuel (lipolysis), and exogenous
insulin spares carbohydrates at the expense of fats.

ANS: C
Ketosis occurs as a result of fat catabolism when intracellular glucose is unavailable for energy production.
The client with type 1 diabetes becomes ketotic because he or she produces no insulin and blood glucose
cannot enter the cells. In type 2 diabetes, natural insulin production continues, although at a greatly reduced
level. This level is not sufficient to keep blood glucose levels in the normal range but permits just enough
glucose to enter cells for energy production so that fats are not catabolized for this purpose.

57. Which clinical manifestation indicates to the nurse that the therapy for the client with
hyperglycemic, hyperosmolar, nonketotic syndrome (HHNS) needs to be adjusted?
A. The client's serum potassium level increased from 2.8 mEq/L to 3.2 mEq/L.
B. The client's blood osmolarity has decreased from 350 mOsm to 330 mOsm.
C. The client's score on the Glasgow Coma Scale is unchanged from 3 hours ago.
D. The client's urine has remained negative for ketone bodies for the past 3 hours.

ANS: C
A slow but steady improvement in CNS functioning is the best indicator of therapy effectiveness for
HHNS. Lack of improvement in level of consciousness may indicate inadequate rates of fluid replacement.

COMPLETION

1. The earliest sign of nephropathy is ____________________.

ANS:
microalbuminuria
Rationale: Chronic high blood glucose causes hypertension in the kidney blood vessels and excess kidney
perfusion. The blood vessels become leaky, especially in the glomerulus which allows filtration of larger
particles (including albumin) which form deposits in the kidney tissue and blood vessels. The vessels
narrow, decreasing kidney oxygenation and leading to kidney hypoxia and cell death.

OTHER

1. Which of the following does not affect the results of self-monitoring of blood glucose
(SMBG)? (Select all that apply.)
A. Hypotension
B. Quantity of blood
C. Peripheral neuropathy
D. Altitude and temperature
E. Anemia
F. Triglyceride level
G. Accuracy of BGM monitor
H. Storage of test strips

ANS:
C
Rationale: The presence of peripheral neuropathy affects sensation; it does not affect the ability of the
operator to obtain a sufficient drop of blood for testing.

Chapter 72: Assessment of the Renal/Urinary System


MULTIPLE CHOICE

1. Confirmed by palpation and x-ray study, the client's right kidney is lower than the left
kidney. What is the nurse’s interpretation of this finding?
A. The client has a problem involving the right kidney.
B. The client has a problem involving the left kidney.
C. The client has both kidneys in the normal position.
D. The client is at increased risk for kidney impairment.

ANS: C
Normally, the right kidney is positioned somewhat lower than the left kidney. This anatomic difference in
otherwise symmetric organs is caused by liver displacement. The significance of this difference is that the
right kidney is easier to palpate in an adult than is the left kidney.

2. What would be the response if a person's nephrons were not able to filter normally due to
scarring of the proximal convoluted tubule leading to inhibition of reabsorption?
A. Increased urine output, fluid volume deficit
B. Decreased urine output, fluid volume deficit
C. Increased urine output, fluid volume overload
D. Decreased urine output, fluid volume overload

ANS: A
The nephrons filter about 120 mL/min. Most of this filtrate is reabsorbed in the proximal convoluted
tubule. If the tubule were not able to reabsorb the fluid that has been filtered, urine output would greatly
increase, leading to rapid and severe dehydration.

3. With a renal threshold for glucose of 220 mg/dL, what is the expected response when a
client has a blood glucose level of 400 mg/dL?
A. 400 mg/dL of excreted glucose in the urine
B. 220 mg/dL of excreted glucose in the urine
C. 180 mg/dL of glucose is excreted in the urine
D. No excreted glucose in the urine

ANS: C
Blood glucose is freely filtered at the glomerulus. Therefore, if a client has a blood sugar level of 400
mg/dl, the filtrate in the proximal convoluted tubule will have a glucose concentration of 400 mg/dL. With
a renal threshold of 220 mg/dl, a total of 220 mg/dL of the 400 mg/dL will be reabsorbed back into the
systemic circulation, and the final urine will have a glucose concentration of 180 mg/dL.

4. Which of the following conditions are associated with oversecretion of rennin?


A. Alzheimer's disease
B. Hypertension
C. Diabetes mellitus
D. Diabetes insipidus

ANS: B
Renin is secreted when special cells in the DCT, called the macula densa, sense changes in blood volume
and pressure. When the macula densa cells sense that blood volume is low, blood pressure is low, or blood
sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads
to a series of reactions that cause the secretion of the hormone aldosterone. This hormone increases kidney
reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels.
Inappropriate or excessive renin secretion is a major cause of persistent hypertension.

5. The client is taking a medication for an endocrine problem that inhibits aldosterone
secretion and release. To what complications of this therapy should the nurse be alert?
A. Dehydration, hypokalemia
B. Dehydration, hyperkalemia
C. Overhydration, hyponatremia
D. Overhydration, hypernatremia

ANS: B
Aldosterone is a mineralocorticoid that increases the reabsorption of water and sodium in the kidney at the
same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone
secretion or release increases the client's risk for excessive water loss and potassium reabsorption.

DIF: Cognitive Level: Application or higher


TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity

6. What is the result of stimulation of erythropoietin production in the kidney tissue?


A. Increased blood flow to the kidney
B. Inhibition of vitamin D and loss of bone density
C. Increased bone marrow production of red blood cells
D. Inhibition of the active transport of sodium, leading to hyponatremia

ANS: C
Erythropoietin is produced in the kidney and released in response to decreased oxygen tension in the renal
blood supply. Erythropoietin stimulates red blood cell (RBC) production in the bone marrow.

7. Which of the following muscle actions results in voluntary urination?


A. Detrusor contraction, external sphincter contraction
B. Detrusor contraction, external sphincter relaxation
C. Detrusor relaxation, external sphincter contraction
D. Detrusor relaxation, external sphincter relaxation

ANS: B
Voiding becomes a voluntary act as a result of learned responses controlled by the cerebral cortex that
cause contraction of the bladder detrusor muscle and simultaneous relaxation of the external urethral
sphincter muscle.

8. Which change in renal or urinary functioning as a result of the normal aging process
increases the older client's risk for infection?
A. Decreased glomerular filtration
B. Decreased filtrate reabsorption
C. Weakened sphincter muscles
D. Urinary retention

ANS: D
Incomplete bladder emptying for whatever reason increases the client's risk for urinary tract infections as a
result of urine stasis providing an excellent culture medium that promotes the growth of microorganisms.

9. The client reports the regular use of all the following medications. Which one alerts the
nurse to the possibility of renal impairment when used consistently?
A. Antacids
B. Penicillin
C. Antihistamine nasal sprays
D. Nonsteroidal anti-inflammatory drugs

ANS: D
NSAIDs inhibit prostaglandin production and decrease blood flow to the nephrons. They can cause an
interstitial nephritis and renal impairment.

10. A nurse observes that the client's left flank region is larger than the right flank region.
What is the nurse’s best action?
A. Ask the client if he or she participates in contact sports and has been recently injured.
B. Document the finding as the only action on the appropriate flowsheet.
C. Apply a heating pad to the left flank after inspecting the site for signs of infection.
D. Anticipate further diagnostic testing after sharing informing the physician of this finding.

ANS: D
Asymmetry of the flank or a unilateral protrusion may indicate an enlargement of a kidney. The
enlargement may be benign or may be associated with a hydronephrosis or mass on the kidney.

11. Which assessment maneuvers should the nurse perform first when assessing the renal
system at the same time as the abdomen?
A. Abdominal percussion
B. Abdominal auscultation
C. Abdominal palpation
D. Renal palpation

ANS: B
Auscultation precedes percussion and palpation because the nurse needs to auscultate for abdominal bruits
before palpation or percussion of the abdominal and renal components of a physical assessment.

12. The client has an elevated blood urea nitrogen (BUN) level and an increased ratio of
blood urea nitrogen to creatinine. What is the nurse’s interpretation of these laboratory results?
A. The client probably has a urinary tract infection.
B. The client may be overhydrated.
C. The kidney may be hypoperfused.
D. The kidney may be damaged.

ANS: C
When dehydration or renal hypoperfusion exist, the BUN level rises more rapidly than the serum creatinine
level, causing the ratio to be increased, even when no renal dysfunction is present.

13. The client's urine specific gravity is 1.018. What is the nurse’s best action?
A. Ask the client for a 24-hour recall of liquid intake.
B. Document the finding as the only action.
C. Obtain a specimen for culture.
D. Notify the physician.

ANS: B
This specific gravity is within the normal range for urine.

14. Which condition would trigger the release of antidiuretic hormone (ADH)?
A. Plasma osmolarity decreased secondary to overhydration.
B. Plasma osmolarity increased secondary to dehydration.
C. Plasma volume decreased secondary to hemorrhage.
D. Plasma volume increased with edema formation.

ANS: B
Antidiuretic hormone is triggered by a rising ECF osmolarity, especially hypernatremia.

15. The female client's urinalysis shows all the following characteristics. Which should the
nurse document as abnormal?
A. pH 5.6
B. Ketone bodies present
C. Specific gravity is 1.030
D. Two white blood cells per high-power field

ANS: B
Ketone bodies are byproducts of incomplete metabolism of fatty acids. Normally, there are no ketones in
urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy.

16. The client scheduled for intravenous urography informs the nurse of the following
allergies. Which one should the nurse report to the physician immediately?
A. Seafood
B. Penicillin
C. Bee stings
D. Red food dye

ANS: A
Clients with seafood allergies often have severe allergic reactions to the standard dyes used during
intravenous urography.

17. The client scheduled to have an intravenous urogram is a diabetic and taking the
antidiabetic agent metformin. What should the nurse tell this client?
A. “Call your diabetes doctor and tell him or her that you are having an intravenous urogram
performed using dye.”
B. “Do not take your metformin the morning of the test because you are not going to be eating
anything and could become hypoglycemic.”
C. “You must start on an antibiotic before this test because your risk of infection is greater as a result
of your diabetes.”
D. “You must take your metformin immediately before the test is performed because the IV fluid and
the dye contain a significant amount of sugar.”

ANS: A
Metformin can cause a lactic acidosis and renal impairment as an interaction with the dye. This drug must
be discontinued for 48 hours before the procedure and not started again after the procedure until urine
output is well established.

18. The client is going home after urography. Which instruction or precaution should the
nurse teach this client?
A. “Avoid direct contact with the urine for 24 hours until the radioisotope clears.”
B. “You are likely to experience some dribbling of urine for several weeks after this procedure.”
C. “Be sure to drink at least 3 L of fluids today to help eliminate the dye faster.”
D. “Your skin may become slightly yellow-tinged from the dye used in this procedure.”

ANS: C
Dyes used in urography are potentially nephrotoxic.

19. Two hours after a closed percutaneous kidney biopsy, the client reports a dramatic
increase in pain. What is the nurse’s best first action?
A. Reposition the client on the operative side.
B. Administer prescribed opioid analgesic.
C. Assess pulse rate and blood pressure.
D. Check the Foley catheter for kinks.

ANS: C
An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of internal
hemorrhage.

20. The client is scheduled to have a renogram (kidney scan). She is concerned about
discomfort during the procedure. What is the nurse’s best response?
A. “Before the test you will be given a sedative to reduce any pain.”
B. “A local anesthetic agent will be used, so you might feel a little pressure but no pain.”
C. “Although this test is very sensitive, there is no more discomfort than you would have with an
ordinary x-ray.”
D. “The only pain associated with this procedure is a small needle stick when you are given the
radioisotope.”

ANS: D
The test involves an intravenous injection of the radioisotope and the subsequent recording of the emission
by a scintillator.

OTHER

1. Select the results (in italics) that are normal in a urinalysis.


A. pH 6
B. Specific gravity 1.015
C. Protein small
D. Sugar negative
E. Nitrate small
F. Leukocyte esterase positive
G. Bilirubin negative

ANS:
A, B, D, G
Rationale: The abnormal values are indicative of a urinary tract infection. As a result of protein, nitrates,
and leukoesterase in the urine, the nurse can expect the laboratory to analyze microscopic sediment
including evaluating the sample for the presence of crystals, casts, WBCs, and RBCs.

Chapter 73: Interventions for Clients with Urinary Problems

MULTIPLE CHOICE

1. Which client is at greatest risk for development of a bacterial cystitis?


A. Older female client not taking estrogen replacement
B. Older male client with mild congestive heart failure
C. Middle-aged female client who has never been pregnant
D. Middle-aged male client who is taking cyclophosphamide for cancer therapy

ANS: A
Females at any age are more susceptible to cystitis than men because of the shorter urethra in women.
Postmenopausal women who are not on hormone replacement therapy are at an increased risk for bacterial
cystitis because of changes in the cells of the urethra and vagina.

2. With which of the following clients, all of whom are experiencing the clinical
manifestations of a urinary tract infection, should the nurse suspect a fungal infection?
A. 40-year-old woman with systemic lupus erythematosus
B. 60-year-old man with an enlarged prostate gland
C. 22-year-old woman who is sexually active
D. 48-year-old man with diabetes mellitus

ANS: D
Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal
urinary tract infections.

3. With which laboratory finding for a client with a urinary tract infection should the nurse
notify the physician immediately?
A. Left shift in the WBC differential
B. Serum white blood cell count of 8000/mm3
C. Presence of red blood cells in the urine
D. Presence of white blood cells in the urine

ANS: A
A left shift most commonly occurs with urosepsis, a condition that has a 15% mortality rate. Left shifts
rarely occur with uncomplicated cystitis.

4. Which statement made by the client who has a recurrent urinary tract infection indicates
correct understanding regarding antibiotic therapy?
A. “If my urine becomes lighter and clear, the infection is gone and I can stop taking my medicine.”
B. “Even if I feel completely well, I should take the medication until it is gone.”
C. “When my urine no longer burns, I will no longer need to take the antibiotics.”
D. “If my temperature goes above 100° F, I should take twice as much medicine.”

ANS: B
Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes
the prescribed medication for the entire course and not just when symptoms are present.

5. The 55-year-old female client has had two episodes of bacterial urethritis in the last 6
months. She asks her nurse why this is happening to her now. What is the nurse’s best response?
A. “Your immune system becomes less effective as you age.”
B. “Low estrogen levels can make the tissue more susceptible to infection.”
C. “You should be more careful with your personal hygiene in this area.”
D. “It is likely that your sexual partner is traumatizing this area.”

ANS: B
Low estrogen levels decrease moisture and the type of secretions in the perineal area, predisposing it to the
development of infection.

6. The hospitalized client with a urethral retention catheter has cystitis. What is the priority
nursing diagnosis for this client?
A. Risk for Infection
B. Disturbed Body Image
C. Risk for Impaired Skin Integrity
D. Risk for Urge Urinary Incontinence

ANS: A
The most common cause of sepsis among hospitalized clients is a urinary tract infection. Ascending
infections from cystitis with an indwelling catheter is a major source of such infections.

7. The client with severe bacterial cystitis is prescribed to take cefadroxil (Duricef) and
phenazopyridine (Pyridium). What precaution or instruction should the nurse teach this client regarding the
drug regimen?
A. “Do not take these drugs with food or milk.”
B. “Stop these drugs if you think you are pregnant.”
C. “Do not be alarmed by the discoloration of your urine.”
D. “Drink a liter of cranberry juice each day to acidify your urine.”

ANS: C
Phenazopyridine discolors urine most commonly to a deep reddish orange. Many clients think they have
blood in their urine when they see this coloration. In addition, the urine can permanently stain clothing.
8. What is the priority nursing diagnosis for the client with stress incontinence?
A. Chronic Pain
B. Social Isolation
C. Risk for Infection
D. Risk for Impaired Skin Integrity

ANS: B
Clients with stress incontinence who are alert and cognitively intact often avoid social interaction because
of embarrassment and concern that they may have a detectable urine odor. Some of the incontinence pads
may limit clothing choices for some social situations.

9. How is urge incontinence different from stress incontinence?


A. A hallmark of urge incontinence is a postvoiding residual volume less than 50 mL and the
hallmark of stress incontinence is a postvoiding residual volume greater than 50 mL.
B. Stress incontinence occurs in cognitively intact individuals and urge incontinence occurs in clients
who have some degree of cognitive impairment.
C. Stress incontinence occurs because of weak pelvic floor muscles and urge incontinence occurs
because of abnormal bladder contractions.
D. Urge incontinence can be managed by increasing fluid intake and stress incontinence can be
managed by decreasing fluid intake.

ANS: C
Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincters and
cannot tighten the urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is
common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and
delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor
muscle. Abnormal detrusor contractions may be a result of neurologic abnormalities or may occur with no
known abnormality.

10. Which statement made by the client with stress incontinence regarding diet therapy
indicates a need for clarification of the therapy.
A. “I will limit my total intake of fluids.”
B. “I will avoid drinking alcoholic beverages.”
C. “I will avoid drinking coffee and other caffeinated beverages.”
D. “I will try to reduce my total body weight by at least 10%.”

ANS: A
Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Alcoholic and
caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing
incontinence.

11. For which client experiencing incontinence should the nurse plan an alternative to
bladder training?
A. 70-year-old man who is confused
B. 70-year-old woman with diabetes
C. 45-year-old man with early-stage renal failure
D. 45-year-old woman with early menopause
ANS: A
For a bladder training program to succeed in urge incontinence, the client must be alert, aware, and able to
resist the urge to urinate.

12. For which client who has urine incontinence problems should the nurse plan an
alternative to the use of intermittent self-catheterization for urine elimination?
A. 85-year-old female client
B. 60-year-old female client who is blind
C. 62-year-old male client with dementia
D. 48-year-old male client who has paraplegia

ANS: C
Clients of any age with a variety of impairments and disabilities can participate in intermittent self-
catheterization. The two main requirements are that the client is cognitively intact and can reach the area.

13. A nurse is working with a client who has overflow incontinence, helping the client to
achieve bladder control. Which intervention is most likely to be effective in stimulating initiation of
voiding for this client?
A. Stroking the medial aspect of the thigh
B. Using intermittent catheterization
C. Providing digital anal stimulation
D. Using the Valsalva maneuver

ANS: D
In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that
achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate) can initiate
voiding.

14. The daughter and caretaker of a confused client with functional incontinence is crying
and asks about having an in-dwelling catheter placed in her mother so that there is less laundry and the
house does not smell so much like urine. What is the nurse’s best response?
A. “You must be very aggravated at this situation. That plan will take care of all urinary-related
problems, and I will call the physician with this request.”
B. “I know you are tired. However, having a catheter in all the time creates a large risk for infection. I
will teach you how to insert the catheter, which should be used just at night.”
C. “With wet clothing, your mother is also at an increased risk for skin breakdown. Rather than place
a catheter in long-term, we can teach you and your mother how to perform intermittent catheterization to
drain the bladder 6 to 8 times each day and help her keep dry.”
D. “Although a catheter seems easier, it would not be good for your mother. There are many types of
pads that can be placed or worn to prevent smells and leaks. Social services can help you obtain these
supplies at a reasonable cost.”

ANS: D
In-dwelling catheters are used only as a last resort because of the risk for ascending urinary tract infections
and sepsis. Containment pads should be attempted as a means of controlling wetness first. If the client has
skin breakdown, an in-dwelling catheter can be placed temporarily until the area has healed.

15. Which client is at highest risk for developing a renal calculus?


A. 75-year-old man with diabetes mellitus
B. 25-year-old woman who is 6 months pregnant
C. 64-year-old woman with mild congestive heart failure
D. 35-year-old man who had a renal calculus 1 year ago

ANS: D
Age and the other conditions listed do not contribute to the formation of renal calculi. The greatest risk
factor for calculus formation is a history of a previous stone.

16. The client with no known metabolic defects has passed a renal calculus and worries about
a recurrence. What prevention strategy should the nurse teach this client?
A. “Drink at least 3 to 4 liters of fluid each day.”
B. “Avoid dairy products and other sources of calcium.”
C. “Avoid aspirin and aspirin-containing products.”
D. “Start taking antibiotics at the first sign of a stone.”

ANS: A
Dehydration contributes to the precipitation of minerals to form a stone. Ingestion of calcium or aspirin
does not cause a stone. Antibiotics neither prevent nor treat a stone.

17. What statement made by the client who has kidney stones from secondary hyperoxaluria
indicates correct understanding of the role of dietary modification as therapy for this condition?
A. “No modifications are needed because your type of stones is not caused by diet.”
B. “I will avoid dark green leafy vegetables, chocolate, and nuts.”
C. “I will avoid all dairy products and vitamin D.”
D. “I will avoid wine, meat, and shellfish.”

ANS: B
Secondary hyperoxaluria is caused by an excessive ingestion of foods containing large amounts of oxalate,
such as spinach, rhubarb, Swiss chard, collard greens, cocoa, beets, wheat germ, pecans, peanuts, okra,
chocolate, and lime peel.

18. The client with a renal calculus has just returned from an extracorporeal shock wave
lithotripsy procedure and the nurse finds an ecchymotic area on the client's right lower back. What is the
nurse’s best first action?
A. Notify the physician.
B. Apply ice to the site.
C. Place the client in the prone position.
D. Document the observation as the only action.

ANS: B
The shock waves can cause bleeding into the tissues through which the waves pass. Application of ice can
reduce the extent and discomfort of the bruising.

19. Which drug should the nurse be prepared to administer to the client diagnosed with renal
calculi from hyperuricemia?
A. Allopurinol (Zyloprim)
B. Captopril (Capoten)
C. Chlorothiazide (Diuril)
D. Phenazopyridine (Pyridium)

ANS: A
Allopurinol inhibits the enzyme that converts purine metabolites into uric acid, thereby reducing the
amount of uric acid present for precipitation into stones.

20. The client who underwent a nephrolithotomy procedure 24 hours ago now has a fever of
101° F. What is the nurse’s best action?
A. Apply a cooling blanket.
B. Strain the urine.
C. Notify the physician.
D. Document the finding as the only action.

ANS: C
The elevated temperature indicates a possible infection. Treatment must be initiated as soon as possible to
prevent septic complications.

21. Which personal factor in a client diagnosed with bladder cancer is most contributory to
this problem?
A. Has worked in a lumber yard for 10 years
B. A 50 pack-year cigarette smoking history
C. Numerous episodes of bacterial cystitis
D. History of gonorrhea

ANS: B
The greatest risk factor for bladder cancer is a long history of tobacco use.

22. The client with bladder cancer is scheduled to have intravesical chemotherapy. Which
statement made by the client indicates correct understanding of this therapy?
A. “My hair will start growing back in 3 to 6 weeks after my chemotherapy is over.”
B. “I can expect my white blood cell counts to drop and increase my risk for infections.”
C. “I will have few if any side effects from this type of chemotherapy.”
D. “Chemotherapy only controls cancer, it doesn't cure it.”

ANS: C
Intravesical chemotherapy involves instilling the chemotherapy agents directing in the bladder. The side
effects are local, not systemic.

23. The client with bladder cancer has undergone a complete cystectomy with ileal conduit.
Four hours after the surgery, the nurse observes the stoma to be cyanotic. What is the nurse’s best action?
A. Document the observation as the only action.
B. Loosen the dressing.
C. Notify the physician.
D. Apply oxygen.

ANS: C
A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent
necrosis.

OTHER

1. A 55-year-old client has had two episodes of bacterial cystitis in the last 6 months. Which
of the following questions should the nurse ask? (Select all that apply.)
A. How much water do you drink per day?
B. Do you take estrogen replacement?
C. Does anyone in your family have a history of cystitis?
D. Do you have any disease like diabetes that may affect your immune system?
E. Are you on steroids or other immunosuppressant drugs?
F. Do you void before intercourse?
G. Do you drink grapefruit juice every day?

ANS:
A, B, D, E
Rationale: Fluid intake, estrogen levels, immunosuppression, hyperglycemia, and increased bacterial count
from intercourse all can increase the chance of recurrent cystitis. Family history is usually nonsignificant,
voiding after intercourse is more important than before to lower the bacterial count, and cranberry juice, not
grapefruit juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

2. The nurse is teaching the client about self-catheterization in the home setting. (Select all
that apply.)
A. Wash hands before and after self-catheterization.
B. Use a large-lumen catheter for each catheterization.
C. Use lubricant on the tip of the catheter prior to insertion.
D. Self-catheterize every 12 hours.
E. Use sterile gloves for the procedure.
F. Cleanse the catheter with soap and water between each use.
G. Store the catheter in a clean towel or plastic bag between use.

ANS:
A, C, F, G
Rationale: Washing hands decreases self-contamination, lubricant decreases trauma, and only clean
technique is necessary in the home (sterile technique in the hospital). A small-lumen catheter should be
used to minimize trauma, self-catheterization should be done every 6 to 8 hours depending on fluid intake,
and 12 hours leads to increased urinary retention, which leads to bacterial growth.

Chapter 74: Interventions for Clients with Renal Disorders

MULTIPLE CHOICE

1. Which clinical manifestation in a client with renal impairment is associated with


polycystic kidney disease rather than an infectious process?
A. Flank pain
B. Periorbital edema
C. Bloody and cloudy urine
D. Enlarged or protruding abdomen
ANS: D
A protruding and distended abdomen is common because the cystic kidneys swell and push abdominal
contents forward and displace other abdominal organs.

2. The client is a 30-year-old man who has type 1 polycystic kidney disease (PKD-1). He
asks whether his children could develop this disease. What is the nurse’s best response?
A. “Because there is no identifiable pattern of inheritance with this disease, your children are not at
an increased risk for developing polycystic kidney disease.”
B. “Because the disease is sex-linked (x-linked) recessive, only your sons will be affected.”
C. “Because this is a recessive disorder, your wife would also have to have the disease for your
children to have polycystic kidney disease.”
D. “Because this is a dominant disorder, each of your children would have a 50% risk of having
polycystic kidney disease.”

ANS: D
Polycystic kidney disease type 1 (PKD-1) is transmitted as an autosomal dominant trait and, therefore, is
not gender-specific. If one parent has PKD-1, each child has a 50% risk for the disorder. If both parents
have PKD-1, the risk is even greater.

3. The client with polycystic kidney disease and hypertension is prescribed to take a diuretic
for blood pressure control. Which of the following statements by the client indicates a need for clarification
regarding this management?
A. “I will weigh myself every day.”
B. “I will drink only 1 L of fluid each day.”
C. “I will avoid aspirin and aspirin-containing drugs.”
D. “I will avoid nonsteroidal anti-inflammatory drugs.”

ANS: B
Diuretics for blood pressure control can lead to fluid volume depletion and decrease blood flow to the
kidney, further decreasing renal function. Fluid volume intake is not restricted until the kidney no longer
responds to diuretics.

4. What dietary modifications should the nurse teach the client with polycystic kidney
disease?
A. Increased protein intake, decreased potassium intake
B. Increased fiber intake, decreased sodium intake
C. Decreased fluid intake, increased magnesium intake
D. Decreased calcium intake, increased chloride intake

ANS: B
Major problems associated with PKD are constipation and hypertension. An increase in dietary fiber and
unrestricted fluid intake can help prevent or relieve constipation. Hypertension is a serious problem, and a
sodium restriction can be helpful.

5. Which client is at greatest risk for a hydroureter?


A. 68-year-old man with chronic hypertension
B. 68-year-old woman with diabetic nephropathy
C. 28-year-old woman with frequent cystitis
D. 28-year-old man with frequent renal calculi

ANS: D
A hydroureter is most commonly caused by obstruction in the mid to upper portion of the urinary system.
Large kidney stones (renal calculi) can block the flow of urine either in the renal pelvis or in the ureter. The
kidney continues to make urine and the volume backs up into the kidney.

6. Which clinical manifestation in a client with a urinary tract infection alerts the nurse to
the possibility of acute pyelonephritis?
A. Burning on urination
B. Cloudy, dark urine
C. Fever and chills
D. Hematuria

ANS: C
Lower urinary tract infections (cystitis and urethritis) are rarely associated with systemic symptoms of
fever and chills.

7. The 48-year-old client with diabetes mellitus is being treated for her third episode of
acute pyelonephritis in the past year. She asks what she could do to help prevent these infections. What is
the nurse’s best response?
A. “Test your urine daily for the presence of ketone bodies and proteins.”
B. “Use tampons rather than sanitary napkins during your menstrual period.”
C. “Drink more water and try to empty your bladder at least every 2 to 3 hours while you are awake.”
D. “Inject your insulin in larger doses or more frequently to keep your blood sugar lower so the
microorganisms have fewer nutrients for growth.”

ANS: C
Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically
elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable
climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the
client's sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less
frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water)
and voiding frequently prevent stasis and bacterial overgrowth.

8. The client has just been diagnosed with acute glomerular nephritis. Which question
should the nurse ask this client in attempting to establish a cause?
A. “Are you sexually active?”
B. “Do you have pain or burning on urination?”
C. “Has anyone in your family had chronic kidney problems?”
D. “Have you had any type of infection within the last 2 weeks?”

ANS: D
The most common cause of acute glomerular nephritis is the presence of a systemic infection resulting in
the formation of antigen-antibody complexes, which precipitate in the kidney tissues.

9. The client with acute glomerular nephritis has periorbital edema. What additional
assessment should the nurse obtain or perform with this client?
A. Auscultate breath sounds.
B. Check blood glucose levels.
C. Measure deep tendon reflexes.
D. Test urine for the presence of protein.

ANS: A
Acute glomerular nephritis can cause sodium and water retention. When clients have edema, they may also
have circulatory overload with pulmonary edema.

10. The client with glomerular nephritis has a glomerular filtration rate (GFR) of 40 mL/min,
as measured by a 24-hour creatinine clearance. What is the nurse’s interpretation of this finding?
A. Excessive glomerular filtration rate, client at risk for dehydration
B. Excessive glomerular filtration rate, client at risk for fluid overload
C. Reduced glomerular filtration rate, client at risk for dehydration
D. Reduced glomerular filtration rate, client at risk for fluid overload

ANS: D
The glomerular filtration rate refers to the initial amount of urine that the kidneys filter from the blood. In
the healthy adult, the normal glomerular filtration rate ranges between 100 and 120 mL/min, most of which
is reabsorbed in the kidney tubules, so that the normal urine output rate averages 30 to 60 mL/hr. A GRF of
40 mL/min is drastically reduced, with the client experiencing fluid retention and a risk for hypertension
and pulmonary edema as a result of excess vascular fluid.

11. What is the pathologic process causing the decreased GFR associated with acute
glomerular nephritis?
A. Decreased renal-induced constriction of the renal arteries
B. Necrosis of 70% or more of the nephrons secondary to increased kidney interstitial hydrostatic
pressure
C. Scar tissue formation throughout the proximal convoluted tubule secondary to toxin-induced
collagen synthesis
D. Thickened capillary membranes secondary to immune complex deposition and cellular
proliferation

ANS: D
Most forms of glomerulonephritis are associated with accumulation of immune complexes in the glomeruli
and glomerular capillaries, thickening the capillaries and impeding filtration. The immune complexes
activate many mediators, including complement, leukocytes, and coagulation proteins, responsible for the
resultant renal tissue injury.

12. What clinical manifestation indicates to the nurse that the client with glomerular nephritis
being treated in the community is responding as expected to the prescribed treatment?
A. The client has lost 11 pounds in the past 10 days.
B. The client's urine specific gravity is 1.048.
C. No blood is observed in the client's urine.
D. The client is thirsty.

ANS: A
Fluid retention is a major feature of glomerular nephritis. This weight loss represents fluid loss, indicating
that the glomeruli are performing the function of filtration.

13. The client has nephrotic syndrome with a normal glomerular filtration rate. What dietary
modification should the nurse teach this client?
A. Decreased intake of protein
B. Increased intake of protein
C. Decreased intake of carbohydrates
D. Increased intake of carbohydrates

ANS: B
In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema
formation. If glomerular filtration is normal or near-normal, the increased protein loss should be matched
by an increased intake of protein.

14. What is the priority nursing diagnosis for the client with nephrosclerosis?
A. Risk for Impaired Skin Integrity
B. Risk for Infection
C. Disturbed Body Image
D. Deficient Knowledge

ANS: D
The major cause of nephrosclerosis is poorly controlled hypertension as a result of atherosclerosis and/or
diabetes. Control of the hypertension is essential to preserve renal function and avoid the need for renal
replacement therapy. Teaching the client the need for and how to manage drug therapy for this condition is
key to preventing complications.

15. In order to plan appropriate care, for which electrolyte imbalance should the nurse
monitor the client with renal cell carcinoma?
A. Hyponatremia
B. Hypernatremia
C. Hypocalcemia
D. Hypercalcemia

ANS: D
Renal cell carcinoma tissues frequently produce ectopic hormones, including parathyroid hormone. The
increased production of parathyroid hormone leads to decreased renal excretion of calcium and an increase
in the serum calcium concentration.

16. In assessing the client who had a radical nephrectomy for a renal cell carcinoma 6 hours
ago, a nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 and the urine output
is 20 mL for this past hour. What is the nurse’s best first action?
A. Position the client so that the remaining kidney is not dependent.
B. Measure the specific gravity of the urine.
C. Document the findings as the only action.
D. Notify the physician.

ANS: D
The radical nature of the surgery and proximity of the surgery to the adrenal gland put the client at risk for
hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both
hemorrhage and adrenal insufficiency. The hypotension is particularly dangerous to the remaining kidney,
which must receive adequate perfusion to function effectively.

17. What should the nurse emphasize when providing home-going instructions to the client
who has undergone a nephrectomy?
A. “Be sure to limit your intake of fluid to no more than 2000 mL/day.”
B. “Test your urine daily for ketone bodies and blood.”
C. “You should never participate in contact sports.”
D. “Avoid all alcoholic beverages.”

ANS: C
The remaining kidney must perform the excreting and metabolic functions of two kidneys. The kidneys are
located in an injury-prone area posterior to the peritoneal cavity and are poorly protected against trauma.
Clients with one kidney should not participate in contact sports.

OTHER

1. The nurse is interviewing a client with a family history of polycystic kidney disease
(PCKD). Which of the following manifestations are typical of PCKD? (Select all that apply.)
A. Nocturia
B. Flank pain
C. Diarrhea
D. Hypotension
E. Dysuria
F. Bloody urine
G. Increased abdominal girth

ANS:
B, F, G
Rationale: Flank pain and abdominal girth size are related to the distention, and bloody urine is seen with
tissue damage secondary to the PCKD. The client may also have constipation and hypertension.

2. The nurse is caring for a client with nephrotic syndrome. Which of the following
manifestations are typical? (Select all that apply.)
A. Proteinuria less than 3 g/24 hr
B. Hypoalbuminemia
C. Fluid volume deficit
D. Lipiduria
E. Dysuria
F. Frequency
G. CVA tenderness
H. Hypotension

ANS:
B, D
Rationale: Nephrotic syndrome is due to glomerular damage and is characterized by proteinuria higher than
3.5 g/24 hr, hypoalbuminemia, edema, and lipiduria. The client may also have hypertension from the fluid
volume excess. CVA tenderness is present with inflammatory changes in the kidney; dysuria and frequency
are present with cystitis.
Chapter 79: Interventions for Male Clients with Reproductive Problems

MULTIPLE CHOICE

1. The client with benign prostatic hyperplasia asks how the enlarged prostate causes
difficulty with urination. What is the nurse’s best response?
A. “The enlarged prostate gland compresses the urethra, blocking urine flow.”
B. “The enlarged prostate gland presses on the kidneys, decreasing the formation of urine.”
C. “The enlarged prostate gland secretes acids that weaken the bladder wall, causing urine dribbling.”
D. “The enlarged prostate gland destroys nerves to the bladder, decreasing your awareness of the
need to urinate.”

ANS: A
The prostate gland encircles the urethra and bladder neck like a doughnut. Enlargement of the gland
constricts the urethra and obstructs the outflow of urine by encroaching on the bladder opening.

2. What technique should the nurse use to determine the volume of residual urine in a client
with benign prostatic hyperplasia?
A. Measure the difference in lower abdominal distention before and after the client voids.
B. Ask the client if he experiences dribbling of urine immediately after voiding.
C. Measure the total amount of urine the client voids with maximum effort.
D. Ask the client to urinate, and then immediately catheterize the bladder.

ANS: D
Residual urine is the amount of urine remaining in the bladder after the client has voided. The volume can
only be accurately ascertained by catheterization.

3. The client is scheduled for a prostatectomy for benign prostatic hypertrophy. On the
morning of surgery, the laboratory report on the client's urine indicates the presence of red blood cells,
white blood cells, and bacteria. What is the nurse’s best action?
A. Document the report as the only action.
B. Remove the Foley catheter.
C. Strain the client's urine.
D. Notify the physician.

ANS: D
Surgery should be cancelled until the urinary tract infection is treated.

4. The client scheduled for a prostatectomy asks whether he will have to have a urinary
catheter in place after surgery. What is the nurse’s best response?
A. “Possibly; it depends on where the surgeon makes the incision.”
B. “Yes, you will need the catheter at least for a day.”
C. “Yes, you will need the catheter until the sutures are removed.”
D. “No, the surgery will fix the problem and you will be able to urinate freely again.”

ANS: B
All clients undergoing prostatectomy will require an indwelling catheter for at least a day, regardless of the
surgical approach used.

5. On the first postoperative day after a transurethral prostatectomy, the client says that the
catheter must not be working properly because he feels the urge to urinate. What is the nurse’s best action?
A. Release the traction on the catheter.
B. Obtain an order to remove the current catheter, allowing the client to void spontaneously.
C. Tell the client that the large size of the catheter makes him feel the urge but that the catheter is
draining properly.
D. Irrigate the catheter with 50 mL of normal saline every hour until the urine is no longer blood-
tinged or filled with debris.

ANS: C
The large diameter of the catheter and the pressure of the retention balloon stimulate the urge to urinate,
even though the bladder is being emptied appropriately by the catheter.

6. The client with a suprapubic catheter in place after a suprapubic prostatectomy is having
bladder spasms. Which of the following drugs should the nurse prepare to administer for relief of this
complication?
A. Atropine
B. Bethanechol
C. Morphine sulfate
D. Dicyclomine hydrochloride

ANS: D
Bladder spasms are painful and can damage the bladder incision. Antispasmodics, such as dicyclomine
hydrochloride (Bentyl, Antispas, Formulex, Dilomine), reduce the spasms and increase the client's comfort.

7. A nurse is continuously irrigating the bladder for the client who has had a prostatectomy.
The irrigation infusion rate is 1000 mL/hr. The client's urine output for the past hour is 200 mL. What is the
nurse’s best first action?
A. Notify the physician.
B. Stop the irrigation flow.
C. Document the finding as the only action.
D. Irrigate the catheter with a large piston syringe.

ANS: B
The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe
decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow
to prevent severe bladder distention. The next action is to check the external system for kinks or
obstruction. If no output occurs, the catheter is irrigated with 30 to 50 mL of normal saline using a large
piston syringe. If the obstruction is not resolved, the physician must be notified.

8. Which statement made by the client being discharged to home after a transurethral
prostatectomy indicates a need for clarification?
A. “I will practice stopping my stream of urine while urinating to strengthen my sphincter control.”
B. “I will limit my intake of liquids to less than 2 L each day to prevent incontinence.”
C. “I will read and play cards with friends as my entertainment for the first 3 weeks.”
D. “I will avoid caffeinated beverages and spicy foods.”
ANS: B
Clients are instructed to drink at least 12 to 14 glasses of water each day (unless contraindicated because of
another medical condition) to keep the urine dilute and stimulate the micturition reflex mechanisms.

9. Which statement made by a client about prostate cancer indicates correct understanding
of the disease?
A. “Prostate cancer is the leading cause of cancer deaths in men in the United States.”
B. “Prostate cancer is the leading type of cancer in men in North America.”
C. “Late onset of puberty and multiple sexual partners increase the risk for prostate cancer.”
D. “The incidence of prostate cancer decreases with age.”

ANS: B
Prostate cancer is the most common form of cancer diagnosed in men and is the second leading cause of
cancer deaths in men in the United States.

10. The 70-year-old client is experiencing all the following clinical manifestations. Which
clinical manifestation alerts the nurse to the possibility of prostate cancer?
A. Nocturia
B. Bone pain
C. Postvoid dribbling
D. Diminished force of the urinary stream

ANS: B
The early clinical manifestations of prostate cancer are similar to those of benign prostatic hyperplasia
(BPH). Bone pain is an uncommon presenting manifestation, different from those of BPH.

11. The client with prostate cancer says that he is now having a lot of pain in his lower back
and legs. What problem does this symptom indicate to the nurse?
A. Arthritis
B. Urinary retention
C. Metastasis to the bone
D. Muscle atrophy from inactivity

ANS: C
The primary site of metastasis for prostate cancer is the bone of the spine and legs.

12. Which finding on digital rectal examination (DRE) is consistent with prostate cancer?
A. The prostate is uniformly enlarged.
B. The texture of the prostate is spongy or elastic.
C. The prostate indents when a finger is pressed on it.
D. There are several stony, irregular nodules within the prostate.

ANS: D
The normal prostate has an elastic or spongy consistency. During benign prostatic enlargement, the entire
prostate enlarges, although the enlargement may be more noticeable on one side. Prostate cancer usually is
manifested as small, very hard, or stony irregularly shaped nodules.

13. What is the priority nursing diagnosis for the client recovering from a perineal
prostatectomy for prostate cancer?
A. Risk for Sexual Dysfunction
B. Disturbed Body Image
C. Risk for Constipation
D. Chronic Pain

ANS: A
The perineal surgical approach for a prostatectomy often involves damage to the perineal nerves, which can
result in permanent erectile dysfunction.

14. In assessing the client who has had a prostatectomy and implantation of an artificial
urinary sphincter, a nurse finds the client's left testis to have an irregularly shaped enlargement. What is the
nurse’s best action?
A. Elevate the scrotum and apply ice to the left testis.
B. Document the finding as the only action.
C. Compare the left testis to the right testis.
D. Notify the physician.

ANS: B
The pump of the artificial urinary sphincter is implanted in the scrotum of males having the procedure so
that they can manipulate the pump, as needed, to drain the bladder appropriately.

15. The 75-year-old client who has been diagnosed with stage 0 prostate cancer is concerned
that surgery has not been planned. What is the nurse’s best response?
A. “This disease is very slow-growing and the risks associated with surgery at your age are not
justified by the outcome.”
B. “Your disease is so advanced that surgery at this point would not increase your chances of cure or
length of survival.”
C. “Your disease is very early stage and slow-growing. Your doctor will monitor you for any
indication that it needs to be removed.”
D. “This stage indicates that you do not really have cancer, just some hyperplasia of the prostate, and
surgery is not necessary for you.”

ANS: C
Stage 0 prostate cancer has no clinical manifestations and is defined only pathologically. It is slow-growing
and may never become a problem to the client. Close follow-up or “watchful waiting” is the common
prescription for this stage, unless the client experiences symptoms of urinary obstruction.

16. Which client is most likely to have organic erectile dysfunction?


A. 40-year-old client who first had sexual intercourse at age 15
B. 50-year-old client who has had diabetes mellitus for 25 years
C. 55-year-old client who had a myocardial infarction 2 years ago
D. 35-year-old client who is the president of a corporation with large debt

ANS: B
Diabetes mellitus causes microvascular and macrovascular complications that decrease the sensation and
autonomic nerve activity required for achievement of an erection.

17. Which statement about sildenafil (Viagra) is true?


A. Frequent use of this medication can lead to the development of hypertension.
B. Sexual stimulation is needed within 30 to 60 minutes of taking the drug to promote the erection.
C. The drug is most effective if taken in the morning, after at least 6 hours of REM sleep.
D. Clients should be cautioned about priapism because of a rebound effect occurring approximately 3
hours after ingestion of the medication.

ANS: B
Clients are instructed to take sildenafil (Viagra) 1 hour before sexual intercourse. Sexual stimulation is
needed within 30 to 60 minutes to promote the erection. Common side effects include headaches, facial
flushing, and diarrhea. Men who take nitrates should not take this drug, because the vasodilation effects can
cause hypotension and decrease perfusion to vital organs.

18. The 20-year-old client has been diagnosed with a seminoma of the right testicle. What
question should the nurse ask this client during assessment?
A. “At what age did you become sexually active?”
B. “Were both your testicles descended at birth?”
C. “Do you participate in masturbation on a regular basis?”
D. “Do you or any members of your family have diabetes mellitus?”

ANS: B
The single greatest risk factor for testicular cancer is cryptorchidism.

19. Which statement made by a client who has undergone a left orchiectomy for testicular
cancer indicates correct understanding about testicular cancer?
A. “I will make sure my sons know how to perform TSE because they are at increased risk for this
type of cancer.”
B. “I will always use a condom, because I am at increased risk for acquiring a sexually transmitted
disease.”
C. “I will wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle.”
D. “I will continue to perform TSE monthly on my remaining testicle.”

ANS: D
Treatment (surgery, radiation, or chemotherapy) for testicular cancer does not protect the person from
development of testicular cancer in the remaining testicle. A monthly TSE should be performed to monitor
for changes in size, shape, or consistency of the testis.

20. The client who was treated 1 year ago for nonseminomatous testicular cancer now has an
elevated serum alpha-fetoprotein level. What is the nurse’s interpretation of this finding?
A. The client is fertile and should be informed about the need for contraception.
B. The client's testosterone production is below normal.
C. The client has an infection of the reproductive tract.
D. The client's cancer has probably recurred.

ANS: D
Alpha-fetoprotein is a tumor marker that is not produced in significant amounts by normal adult tissues. An
increase in the level after treatment most commonly indicates recurrence or metastasis.

21. The client is going home after day surgery for a hydrocele. What information should the
nurse be sure to teach this client?
A. “Report any incisional drainage to the doctor immediately.”
B. Use a condom during intercourse to prevent incisional infection.”
C. “Sit to urinate until all swelling is gone and drainage has stopped.”
D. “Wear the scrotal support device for at least 3 weeks after surgery.”

ANS: D
Edema from residual inflammation can remain for several weeks. This problem is increased if the scrotum
is not supported and can cause the client considerable discomfort.

22. The adult client, who has just undergone circumcision, asks why he has been prescribed
to take a barbiturate sleeping medication because he does not have any difficulty sleeping. What is the
nurse’s best response?
A. “The medication prevents spontaneous nighttime erections that can put tension on the incision.”
B. “This medication ensures that you will sleep deeply enough that you are unlikely to touch the
incision site.”
C. “Your pain will increase when you are in a lying position and you may need the medication to get
to sleep.”
D. “Your prescription is only a precaution. If you have no difficulty sleeping, do not take the
medication.”

ANS: A
Most men have several erections during rapid eye movement (REM) sleep. Erections can put tension on the
incision and sutures. Barbiturate-based sleeping medications suppress the REM phase of sleep.

23. The client with sickle cell anemia, who has been hospitalized for another health problem,
says that he has had an erection for over 4 hours. What is the nurse’s best action?
A. “Tell the client that his sexual conversations are not appreciated.”
B. “Attempt to induce urination by applying pressure to the bladder.”
C. “Document the report as the only action.”
D. “Notify the physician.”

ANS: D
Prolonged penile erection, priapism, is common during sickle cell crisis and is considered a urologic
emergency, because circulation to the penis may be compromised and the client may not be able to void.

24. Which intervention or activity should the nurse suggest to the client with chronic
prostatitis to prevent spread of infection to other areas of the urinary tract?
A. “Wear a condom during intercourse.”
B. “Avoid alcohol and caffeinated beverages.”
C. “Be sure to empty your bladder completely at each voiding.”
D. “Try to have sexual intercourse or to masturbate at least twice each week.”
ANS: D
The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which
can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or
masturbation decreases the number of microorganisms present and reduces the risk for further infection.

OTHER

1. When performing an assessment on a client with orchitis, the nurse is aware that which of
the following manifestations are consistent with the diagnosis? (Select all that apply.)
A. Scrotal pain
B. Dysuria
C. Scrotal edema
D. Priapism
E. Penile discharge
F. Inability to ejaculate

ANS:
A, B, C, E
Rationale: The manifestations of orchitis include scrotal pain, edema, reports of heavy feelings in the
involved testicle(s), dysuria, pain on ejaculation, blood in the semen, and discharge from the penis.