Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?
A. Diarrhea
While diarrhea can be a symptom of peptic ulcer disease, it is not typically considered a priority over more severe symptoms.
B. Dyspepsia
Dyspepsia (indigestion) is a common symptom of peptic ulcer disease, but it is not the priority over more concerning symptoms.
C. Epigastric discomfort
Epigastric discomfort is a symptom of peptic ulcer disease, but it is not the priority over more severe symptoms like hematemesis.
D. Hematemesis
Hematemesis (vomiting blood) is a serious and potentially life-threatening symptom of peptic ulcer disease. It is the top priority for assessment and intervention.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
While diarrhea can be a symptom of peptic ulcer disease, it is not typically considered a priority over more severe symptoms.
Choice B reason:
Dyspepsia (indigestion) is a common symptom of peptic ulcer disease, but it is not the priority over more concerning symptoms.
Choice C reason:
Epigastric discomfort is a symptom of peptic ulcer disease, but it is not the priority over more severe symptoms like hematemesis.
Choice D reason:
Hematemesis (vomiting blood) is a serious and potentially life-threatening symptom of peptic ulcer disease. It is the top priority for assessment and intervention.
Similar Questions
A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
A. "Don't worry, most clients dislike the prep more than the procedure itself."
This statement is correct. Providing information about the sedative is appropriate and reassuring for the client who is anxious about pain during the procedure.
B. "After you have signed the consent form, we can talk more about this."
While discussing the procedure after obtaining consent is important, addressing the client's anxiety at this stage is also crucial.
C. "I know you're anxious, but this procedure is recommended for people your age."
Although providing information about the importance of the procedure for the client's age group is relevant, it does not directly address the client's immediate concern about pain.
D. "Before the examination, your provider will give you a sedative that will make you sleepy."
While it's true that many clients find the bowel preparation for a colonoscopy to be the most challenging aspect, this statement does not directly address the client's anxiety about pain during the procedure.
Full Explanation
- A: This response minimizes the client's feelings and may make them feel unheard. It's important for healthcare providers to acknowledge a patient's feelings and provide reassurance in a more empathetic manner.
- B: This response delays addressing the client's concerns and may increase his anxiety. Consent is important, but it should not be a barrier to discussing care and addressing concerns.
- C: This response is factual but does not address the client's immediate concern about pain. It's crucial to address the client's fears directly rather than deflecting to the procedure's necessity.
- D: This response directly addresses the client's concern about pain by informing him of the sedative, which is a common practice to reduce discomfort during a colonoscopy. It provides reassurance and factual information about the procedure's process.
A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities.
Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?
A. Stage 4
This presentation of hepatic encephalopathy includes severe manifestations, such as profound confusion, difficulty in arousal, and the presence of rigidity, indicating advanced neurological impairment. This places the patient in Stage 4, which is the most severe stage of hepatic encephalopathy.
B. Stage 3
Stage 3 is characterized by severe symptoms, such as drowsiness, anxiety, seizures, severe personality changes, confused speech, and shaky hands.
C. Stage 1
Stage 1 is characterized by mild symptoms, such as difficulty thinking, personality changes, poor concentration, and problems with handwriting.
D. Stage 2
Stage 2 is characterized moderate symptoms, such as confusion, forgetfulness, poor judgment, and a musty or sweet breath odor.
Full Explanation
Choice A reason:
This presentation of hepatic encephalopathy includes severe manifestations, such as profound confusion, difficulty in arousal, and the presence of rigidity, indicating advanced neurological impairment. This places the patient in Stage 4, which is the most severe stage of hepatic encephalopathy.
Choice B reason:
Stage 3 is characterized by severe symptoms, such as drowsiness, anxiety, seizures, severe personality changes, confused speech, and shaky hands.
Choice C reason:
Stage 1 is characterized by mild symptoms, such as difficulty thinking, personality changes, poor concentration, and problems with handwriting.
Choice D reason
Stage 2 is characterized moderate symptoms, such as confusion, forgetfulness, poor judgment, and a musty or sweet breath odor.
A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
A. Shiny, moist stoma
A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.
B. Rosebud-like stoma orifice
A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.
C. Purplish-colored stoma
A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.
D. Stoma oozing red drainage
Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.
Full Explanation
Choice A reason:
A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.
Choice B reason:
A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.
Choice C reason:
A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.
Choice D reason:
Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.