Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Crampy and lower left quadrant pain and low-grade fever. Diverticulitis is an inflammatory condition of the diverticula, small pouches that can develop in the colon. The characteristic symptoms of diverticulitis include localized abdominal pain, typically in the lower left quadrant, along with fever. This pain is often described as crampy and can be associated with other symptoms such as bloating and changes in bowel habits. Option A, periodic rectal hemorrhage, is more indicative of diverticular bleeding rather than diverticulitis itself. Option B, hypertension and tachycardia, are not typical symptoms of diverticulitis and may suggest other medical conditions. Option C, vomiting and elevated temperature, are not specific to diverticulitis and are more commonly seen in conditions like gastroenteritis or appendicitis. In an educational context, it is crucial for nursing students to understand the key clinical manifestations of diverticulitis to provide prompt and effective care to patients. Recognizing the hallmark symptoms of this condition enables healthcare providers to initiate appropriate interventions, such as antibiotic therapy and dietary modifications, to manage and treat diverticulitis effectively. This knowledge also helps in differentiating diverticulitis from other gastrointestinal disorders with similar presentations, enhancing the quality of patient care and outcomes.

Correct Answer: A

Rationale: In the case of cholelithiasis, or gallstones, the correct answer is A) Pain in the right upper quadrant, radiating to the shoulder. This is because gallstones commonly cause biliary colic, which presents as a sudden onset of severe, cramping pain in the right upper quadrant of the abdomen that can radiate to the right shoulder or back. This occurs due to the obstruction of the bile duct by the gallstone. Option B) Pain in the right lower quadrant with rebound tenderness is more indicative of appendicitis, not cholelithiasis. Option C) Pain in the left upper quadrant with shortness of breath is not a typical presentation of gallstones. Option D) Pain in the left lower quadrant with mild cramping is more characteristic of conditions like diverticulitis, not cholelithiasis. Educationally, understanding the unique pain patterns associated with different conditions is crucial for accurate assessment and diagnosis in medical-surgical nursing. This knowledge helps nurses provide timely and appropriate interventions for their patients, ensuring optimal outcomes.

Correct Answer: D

Rationale: In the context of postoperative care following an abdominal resection for colon cancer, the Jackson-Pratt drain serves the specific purpose of preventing the accumulation of drainage in the wound. This drain helps to remove excess fluid, blood, and potential contaminants from the surgical site, thereby promoting proper wound healing and reducing the risk of complications such as infection, seroma formation, or delayed wound healing. Option A, irrigating the incision with saline, is not the primary function of a Jackson-Pratt drain. While wound irrigation is a common nursing intervention, the drain itself is not used for this purpose. Option B, preventing bacterial infection of the incision, is indirectly related to the drain's function. By removing excess fluid that may harbor bacteria, the drain can help reduce the risk of infection. However, the primary role of the drain is to prevent fluid accumulation. Option C, measuring the amount of fluid lost after surgery, is not the main purpose of a Jackson-Pratt drain. While the amount of drainage can provide valuable information about a patient's postoperative status, the drain's primary function is to prevent fluid buildup. Educationally, understanding the rationale behind the use of Jackson-Pratt drains postoperatively is crucial for nurses caring for patients undergoing abdominal surgeries. It is vital to grasp the specific purposes of various types of drains to provide effective and evidence-based care, prevent complications, and promote optimal patient outcomes.

Correct Answer: A

Rationale: In colostomy care, it is essential to ensure that the stoma is properly cared for to prevent complications. The correct answer, A) 1/16", is the ideal amount of skin that should remain exposed between the stoma and the ring of the appliance. This minimal exposure helps to prevent skin irritation, injury, and pressure on the stoma, allowing for optimal stoma function and proper appliance sealing. Option B) 1/4″, C) 1/2", and D) 1" all have too much space between the stoma and the appliance ring. Too much exposed skin can lead to leakage, skin breakdown, and poor adherence of the appliance, increasing the risk of infection and discomfort for the patient. Educationally, understanding the correct amount of skin exposure around a stoma is crucial for nursing students caring for patients with colostomies. Proper stoma care not only ensures the physical well-being of the patient but also promotes their emotional and psychological adjustment to living with a colostomy. Students must be able to apply this knowledge in clinical practice to provide safe and effective care for patients with ostomies.

Correct Answer: B

Rationale: In the context of a patient with a possible bowel obstruction like Claire, the priority intervention is to measure abdominal girth (Option B). This is crucial because an increasing abdominal girth can indicate abdominal distension, a common sign of bowel obstruction. Measuring the abdominal girth helps in monitoring for signs of worsening obstruction, such as increased pressure on the bowel walls, which can lead to complications like perforation. Obtaining daily weights (Option A) may be important for fluid balance assessment but is not the priority in this situation where the focus is on identifying and managing a potential complication like bowel obstruction. Similarly, keeping strict intake and output (Option C) and encouraging increased fluids (Option D) are important aspects of nursing care but do not take precedence over assessing for signs of a worsening condition like bowel obstruction. In an educational context, understanding the priority interventions in specific clinical scenarios is vital for nurses to provide timely and effective care to patients. Recognizing the significance of assessing abdominal girth in a patient with a possible bowel obstruction highlights the importance of clinical judgment and critical thinking in nursing practice.