NURS 2207 GI Quiz - Questions, Answers and Rationales The nurse gives a client with hepatitis A information about untoward signs and symptoms related to
... [Show More] the disease. The nurse instructs the client to contact the primary health care provider if the client develops which symptom? 1. Fatigue 2. Anorexia 3. Yellow urine 4. Clay-colored stools Rationale: Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the health care provider about fatigue and anorexia because these symptoms are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine. Which statement by the client, recovering from an acute case of viral hepatitis, indicates understanding of the discharge instructions presented by the nurse? Select all that apply. One, some, or all responses may be correct. 1. "I will avoid alcohol because my liver is scarred and the alcohol causes more damage." 2. "I will eat four to seven small snacks or meals per day." 3 "I will take acetaminophen for pain rather than aspirin." 4 "I will eat foods high in carbohydrates, but moderate in fats and proteins." 5 "I will not have to use condoms during intercourse, because I have beaten this." Rationale: Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis. Clients should avoid alcohol, eat small frequent meals, and eat foods high in carbohydrates and moderate in fats and protein. The client needs to avoid unprotected sex because virus hepatitis is easily transmitted. The parents of a child diagnosed with hepatitis A express concern that other family members may contract hepatitis because they only have one bathroom. Which response would the nurse reply? 1. "I suggest you buy an individual commode seat to use exclusively for your child's bathroom needs." 2. "Your child may use the bathroom, but you need to use disposable toilet seat covers." 3. "You will need to clean the bathroom from top to bottom every time a family member uses it." 4. "All family members, including your child, need to wash their hands after using the bathroom." Rationale: Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper hand washing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. Cleaning the bathroom "from top to bottom" after each use is not feasible. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Hand washing by all family members must be part of the plan to prevent the spread of hepatitis to other family members. Which nursing interventions are required for hepatitis A? 1. Private room with the door closed 2. Gown, mask, and gloves for all persons entering the room 3. Gown and gloves when handling articles contaminated by urine or feces 4. Gowns and gloves only when handling the client's soiled linen, dishes, or utensils Rationale: Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer. Which type(s) of hepatitis most commonly spread by consuming contaminated food and water, or by fecal contamination? Select all that apply. One, some, or all responses may be correct. 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D 5. Hepatitis E Rationale: Hepatitis A and E most commonly are spread through the fecal-oral route. Hepatitis B most commonly is spread through the sharing of needles and through unprotected sex. Hepatitis C and D most commonly are spread through intravenous (IV) drug needle sharing. A client is admitted to the hospital with gastrointestinal bleeding, and a nasogastric (NG) tube is inserted. Prescriptions include irrigating the tube with normal saline as needed to maintain patency. The nurse assesses the NG tube and determines that it is not patent. Which action would the nurse take? 1. Instill normal saline. 2. Assess breath sounds. 3. Auscultate for bowel sounds. 4. Check the tube for placement. Rationale: Checking the tube for placement reduces the risk of introducing the irrigant into the lungs. Instilling normal saline increases the risk of introducing irrigant into the lungs if the tube is not in the stomach. Assessing for breath sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. Auscultating for bowel sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. The nurse is eliciting a health history from a client with ulcerative colitis. Which factor would the nurse consider to be most likely associated with the client's colitis? 1. Food allergy 2. Infectious agent 3. Dietary components 4. Genetic predisposition Rationale: Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn disease, are familial, which suggests that they are hereditary. Although food allergy or an infectious agent may be causative factors, they are not the most common factors. No specific dietary component has been identified. A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication would the nurse assess the client after this surgery? 1. Infection caused by the excretion of feces 2. Injury caused by exposed intestinal mucosa 3. Altered bowel elimination caused by the ostomy 4. Limited water reabsorption caused by removal of intestine Rationale: The continuous excretion of liquid feces may deplete the body of fluids and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-
threatening complication. Although the stoma should be protected from injury and altered bowel elimination is a concern, these are not life-threatening complications. [Show Less]