A nurse is assisting with the care of a client.

Exhibits

Data Collection Findings.

For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease.

Each finding may support more than 1 disease process.

Abdominal cramping

Weight loss

Diarrhea

Anemia

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"}}

The data collection findings are consistent with the following disease processes: Abdominal cramping: This finding can indicate ulcerative colitis, diverticulitis, or Crohn’s disease.

Abdominal cramping is a common symptom of inflammation and infection in the digestive tract. Weight loss: This finding can indicate ulcerative colitis or Crohn’s disease. Weight loss can result from malabsorption, reduced appetite, inflammation, or complications of the disease. Diarrhea: This finding can indicate ulcerative colitis or Crohn’s disease. Diarrhea is caused by increased intestinal motility, inflammation, and ulceration of the mucosa. Anemia: This finding can indicate ulcerative colitis or Crohn’s disease. Anemia can result from chronic blood loss, iron deficiency, vitamin B12 deficiency, or inflammation. The finding of fatty appearance and foul odor of the stool is also consistent with Crohn’s disease, as it suggests steatorrhea (excess fat in the stool) due to malabsorption. The finding of a positive fecal occult blood test is consistent with ulcerative colitis or Crohn’s disease, as it indicates bleeding in the digestive tract.

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Correct Answer is C

Explanation

The correct answer is: c. The AP pulls the pinna up and back.

Choice A reason: The AP inserting the probe with a straight, forward motion is not the correct technique for tympanic temperature measurement. The ear canal does not run straight forward into the head; instead, it curves slightly. Inserting the probe straight forward could potentially damage the ear canal or eardrum and would not provide an accurate temperature reading.

Choice B reason: Pointing the probe posteriorly is also incorrect. The tympanic membrane is located at the end of the ear canal, and the probe should be directed towards it. However, the probe should be angled slightly downward and toward the jawline, not straight back, to align with the ear canal and ensure an accurate reading.

Choice C reason: Pulling the pinna up and back is the correct method for adults and children over one year old. This action straightens the ear canal, allowing the thermometer’s sensor to get a clear path to the tympanic membrane, which is necessary for an accurate temperature reading. For infants, the correct method is to pull the earlobe straight back.

Choice D reason: The AP positioning the client facing her does not directly relate to the technique of measuring tympanic temperature. While it may be necessary for the AP to see the client’s ear, it is not an indication of understanding the correct procedure for tympanic temperature measurement.

A. Wave hands to attract the attention of law enforcement. B. Move wounded clients to a safe area before finding shelter. C. Turn cellular phones to silent mode. D. Attempt to bargain with the shooter.

Correct Answer is C

Explanation

Choice A rationale:

Wave hands to attract the attention of law enforcement. Rationale: This is not recommended during an active shooter situation. Waving hands to attract attention may draw the shooter's focus towards you. It's generally safer to stay quiet and hidden rather than trying to signal law enforcement.

Choice B rationale:

Move wounded clients to a safe area before finding shelter. Rationale: While it's important to provide assistance to wounded clients, moving them during an active shooter situation may not be advisable. It can put both the wounded and those attempting to help them at risk. The priority is to find a safe place and take cover while awaiting law enforcement.

Choice C rationale:

Turn cellular phones to silent mode. Rationale: This is the correct action to take. Turning cellular phones to silent mode helps maintain silence and prevent the phone from ringing or vibrating, potentially alerting the shooter to your location. It's essential to maintain silence and avoid drawing attention during an active shooter situation.

Choice D rationale:

Attempt to bargain with the shooter. Rationale: Attempting to bargain with the shooter is not a recommended action. Engaging with the shooter can escalate the situation and put lives at risk. The best course of action is to hide, stay quiet, and await law enforcement intervention.

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A nurse is assisting with the care of a client. Exhibits Data Collection Findings. For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is C

Explanation

A nurse is assisting with planning an in-service for staff members about active shooter protocols. Which of the following information should the nurse recommend including?

Correct Answer is C

Explanation

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

A nurse is helping to place a client into the prone position. The nurse should use a small pillow to relieve pressure from which of the following areas of the client's body?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A nurse is collecting data from a client who has pernicious anemia.The nurse should identify that which of the following findings increases the client's risk for injury?

A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.Which of the following interventions is the nurse's priority?

A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff.Which of the following sources should the nurse identify as providing the best evidence-based information?

A nurse is assisting with the care of a client.

Exhibits

Data Collection Findings.

For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease.

Each finding may support more than 1 disease process.