HESI Case Studies: Inflammatory Bowel Disease – Flashcards
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The nurse anticipates that Loren will describe her diarrhea as...
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Bloody
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Because rectal bleeding is a common finding in ulcerative colitis, which additional question is important for the nurse to ask Loren?
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"Do you feel fatigued or light-headed?"
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What is the nurse's best response to this information?
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"Ulcerative colitis can cause problems in areas other than the colon."
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Which instruction(s) are important for the nurse to provide Loren regarding food and fluid intake during the stool specimen collection? (Select all that apply.)
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-Avoid red meat. -Do not take supplemental ascorbic acid (Vitamin C).
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Which explanation of the procedure for the barium enema should the nurse provide Loren?
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X-ray is used to visualize the large intestine after barium is instilled.
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What instruction should the nurse provide to a client who just completed a barium enema?
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Drink extra fluids.
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Immediately following the sigmoidoscopy, it is important for the nurse to assess for which manifestation?
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Abdominal guarding
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In responding to Loren, the nurse recognizes that Loren's remarks reflect which of Erikson's developmental stages?
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Intimacy versus isolation
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What is the nurse's best response to Loren?
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"This all seems very overwhelming right now."
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What instruction should the nurse provide Loren?
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"You need to increase the length of time between each dose of the medication."
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Which assessment finding indicates that the Lomotil is having the desired effect?
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Decreased number of bowel movements.
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What instruction is most important to include when teaching Loren about the prednisone?
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Monitor mouth sores for white patches or increased discomfort.
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To maintain this diet, which snack choice is best for Loren?
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Angel food cake and cranberry juice.
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Which additional serum lab value best reflects nutritional malabsorption?
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Albumin 1.5 g/dL
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Since the course of TPN treatment will last about 10 days, the nurse plans to prepare Loren for the insertion of which access device?
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Multi-lumen subclavian catheter
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What action should the nurse take?
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Administer insulin using a sliding scale protocol
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Which medication that Loren is receiving is most likely to contribute to her increased blood glucose level?
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Prednisone (Deltasone)
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The TPN is available in a 1000 mL bag and is prescribed to run at 60 mL per hour. The nurse will expect to hang a new bag in approximately how many hours?
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17
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What action should the nurse take after the remaining TPN has infused?
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Hang a liter of 10% dextrose in water at the same rate of infusion.
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To ensure that Loren remains infection free, which responsibility is best to delegate to an unlicensed assistive personnel (UAP)?
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Obtain and record vital signs every 4 hours
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In providing the care, which division of tasks is best for the nurse to assign?
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After the RN removes the subclavian catheter, the LPN obtains vital signs, and the UAP transports the tip to the lab.
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The nurse recognizes this complication of ulcerative colitis as:
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Toxic megacolon
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The nurse expects to alter Loren's oral intake in what way?
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Loren should be NPO.
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What action should the nurse take?
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Administer the dose as scheduled concurrently with the IV fluids.
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The nurse recognizes that the UAP is protected under what legal statute?
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Civil Rights Legislation.
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What action should the nurse take?
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Instruct the UAP to document all the alleged offenses in writing and submit a copy to the supervisor.
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With whom should the nurse advise the UAP to collaborate?
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A legal aid clinic attorney.
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How should the nurse respond?
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"The drainage will become thicker and appear more yellow or yellow-brown."
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To ensure the best skin protection around the stoma, the nurse should instruct Loren to use what type of product?
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Pectin-based solid skin barrier.
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When should Loren expect to empty her pouch?
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When the pouch is 1/3 to 1/2 full.
