Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing teaching to a client who has diverticulosis about identifying manifestations of diverticulitis. Which of the following client statements indicates an understanding of the teaching?
A. "I will have upper abdominal pain."
Upper abdominal pain is not a typical manifestation of diverticulitis. It is more commonly associated with conditions affecting the upper gastrointestinal tract.
B. "My abdomen will become distended."
Rationale: Diverticulitis is characterized by inflammation or infection of diverticula (small pouches) in the colon. Manifestations of diverticulitis can include abdominal pain (usually left lower quadrant), fever, nausea, vomiting, and changes in bowel habits. Abdominal distension may indicate worsening inflammation or complication of diverticulitis.
C. "My stools will be clay-colored."
Clay-colored stools are more characteristic of liver or bile duct disorders, not diverticulitis.
D. "I will experience gastric reflux."
Gastric reflux is not a common manifestation of diverticulitis. It is more related to gastroesophageal reflux disease (GERD) or other upper gastrointestinal issues.
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Full Explanation
Choice A rationale:
Upper abdominal pain is not a typical manifestation of diverticulitis. It is more commonly associated with conditions affecting the upper gastrointestinal tract.
Choice B rationale:
Rationale: Diverticulitis is characterized by inflammation or infection of diverticula (small pouches) in the colon. Manifestations of diverticulitis can include abdominal pain (usually left lower quadrant), fever, nausea, vomiting, and changes in bowel habits.
Abdominal distension may indicate worsening inflammation or complication of diverticulitis.
Choice C rationale: Clay-colored stools are more characteristic of liver or bile duct disorders, not diverticulitis.
Choice D rationale: Gastric reflux is not a common manifestation of diverticulitis. It is more related to gastroesophageal reflux disease (GERD) or other upper gastrointestinal issues.
Similar Questions
A nurse is developing a plan of care for a client who has epilepsy and was admitted after experiencing a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan?
A. Ensure padded wrist restraints are in the client's room.
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
B. Initiate IV access for the client.
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
C. Administer lorazepam every 4 hr to sedate the client.
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
D. Place an incontinence brief on the client
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
Full Explanation
Choice A rationale:
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
Choice B rationale:
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
Choice C rationale:
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
Choice D rationale:
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
A nurse is teaching the caregiver of a client who has Parkinson's disease. Which of the following instructions should the nurse include?
A. Allow the client extra time to perform ADLS.
Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.
B. Monitor the client for weight gain.
Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.
C. Instruct the client to look down at the feet when walking.
Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.
D. Provide the client with a low-protein diet.
A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.
Full Explanation
Choice A rationale:
Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.
Choice B rationale:
Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.
Choice C rationale:
Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.
Choice D rationale:
A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.
A nurse is assessing a client who has sickle cell anemia. Which of the following findings is the priority for the nurse to report?
A. Slurred speech
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
B. Yellowed sclera
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
C. Ulcers on the ankles
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
D. Swelling in the joints
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.
Full Explanation
Choice A rationale:
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
Choice B rationale:
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
Choice C rationale:
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
Choice D rationale:
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.