ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 57 : Care of Patients with Inflammatory Intestinal Disorders Questions
Question 1 of 5
A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find?
Correct Answer: C
Rationale: High-pitched, rushing bowel sounds are expected in Crohn's disease due to narrowing of the bowel lumen. Positive Murphy's sign indicates gallbladder disease, and rebound tenderness suggests peritonitis. Dull, hypoactive bowel sounds and nightly worsening of cramping are not typical of Crohn's disease.
Question 2 of 5
After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?
Correct Answer: B
Rationale:
Toilet paper can irritate sensitive perineal skin, so warm water rinses or a soft cotton washcloth should be used instead. Aloe vera is not effective for protecting skin from the excoriating effects of liquid stools. The other options describe appropriate care to prevent further irritation.
Question 3 of 5
After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?
Correct Answer: B
Rationale: Adalimumab (Humira) is administered via subcutaneous injection, not orally with meals. Avoiding crowds and sick individuals, recognizing nausea and vomiting as side effects, and practicing good hand hygiene are correct actions, as adalimumab causes immune suppression.
Question 4 of 5
A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, 'I am having trouble swallowing this pill.' Which action should the nurse take?
Correct Answer: C
Rationale: Asacol is an enteric-coated pill that should not be crushed, chewed, or broken, as this would disrupt its delayed-release mechanism. It is not available as a suspension or elixir. A mesalamine enema (Rowasa) is an alternative formulation that can be prescribed if the client cannot swallow the oral form.
Question 5 of 5
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?
Correct Answer: C
Rationale: Severe diarrhea can lead to hypovolemia and electrolyte imbalances, such as low potassium or magnesium, which may cause dysrhythmias. Assessing heart rate and rhythm is the priority to detect potential cardiac complications. Oral mucosa inspection, dietary intake review, and abdominal percussion are important but lower priority.