The nurse provides instructions to a client diagnosed with inflammatory bowel syndrome (IBS) about measures to treat diarrhea caused by acute flare-ups. Which statement by the client indicates a need for further teaching?

"I will eat frequent small meals."

"I will increase the intake of leafy greens and other sources of dietary fiber."

"I will increase fluids."

"I will take prescribed medications on schedule to regulate bowel patterns."

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is correct because eating frequent small meals can help the client with IBS to avoid overloading the digestive system and triggering diarrhea. The nurse should advise the client to eat slowly and chew well, and avoid foods that are spicy, fatty, or gas-producing.

Choice B Reason: This is incorrect because increasing the intake of leafy greens and other sources of dietary fiber can worsen diarrhea by increasing stool bulk and motility. The nurse should advise the client to limit or avoid high-fiber foods, such as whole grains, fruits, vegetables, nuts, and seeds, during acute flare-ups of IBS. The client can gradually reintroduce fiber when the symptoms subside.

Choice C Reason: This is correct because increasing fluids can help the client with IBS to prevent dehydration and electrolyte imbalance caused by diarrhea. The nurse should advise the client to drink at least 8 glasses of water per day and avoid caffeinated, alcoholic, or carbonated beverages that can irritate the bowel or cause gas.

Choice D Reason: This is correct because taking prescribed medications on schedule can help the client with IBS to regulate bowel patterns and reduce diarrhea. The nurse should instruct the client on how to use medications, such as antidiarrheals, antispasmodics, or probiotics, as ordered by the provider. The nurse should also monitor the client for any adverse effects or interactions of the medications.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect because laceration is not an acute traumatic brain injury, but a type of wound that involves tearing or cutting of the skin or other tissues. Laceration can occur as a result of a motor vehicle accident, but it does not cause changes in the GCS or pupil size. The nurse should assess the client's skin for any signs of laceration, such as bleeding, swelling, or infection.
Choice B reason: This is incorrect because acute subdural hematoma is not likely to cause a dilated pupil on the left side. Acute subdural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the arachnoid mater, which are two layers of the meninges that cover the brain. An acute subdural hematoma can cause a rapid decrease in the GCS, but it usually causes a dilated pupil on the same side as the injury, not on the opposite side.
Choice C reason: This is incorrect because intracerebral hemorrhage is not likely to cause a dilated pupil on the left side. Intracerebral hemorrhage is a type of traumatic brain injury that involves bleeding within the brain tissue itself. Intracerebral hemorrhage can cause a gradual decrease in the GCS, but it usually causes neurological deficits that correspond to the location of the bleeding, such as weakness, numbness, or aphasia, not pupillary changes.
Choice D reason: This is correct because epidural hematoma can cause a dilated pupil on the left side. Epidural hematoma is a type of traumatic brain injury that involves bleeding between the dura mater and the skull. Epidural hematoma can cause a lucid interval, which is a period of normal consciousness followed by a sudden decrease in the GCS, and a dilated pupil on the opposite side of the injury, due to compression of the third cranial nerve. The nurse should notify the provider immediately and prepare for emergency surgery.

A. The burned area is yellow in color with severe edema. B. The burned area is black in color and pain is absent. C. The burned area is pink in color with blisters present. D. The burned area is red in color with soft eschar present.

Correct Answer is D

Explanation

Choice A Reason: The burned area is yellow in color with severe edema is not a finding of a deep partial-thickness burn, but a superficial partial-thickness burn. A superficial partial-thickness burn involves the epidermis and the upper layer of the dermis, causing pain, redness, swelling, and blistering.

Choice B Reason: The burned area is black in color and pain is absent is not a finding of a deep partial-thickness burn, but a full-thickness burn. A full-thickness burn involves the epidermis, dermis, and underlying tissues, causing necrosis, charred skin, and loss of sensation.

Choice C Reason:This description aligns with a superficial partial-thickness (first-degree or mild second-degree) burn rather than a deep partial-thickness burn. Superficial partial-thickness burns involve the epidermis and the upper portion of the dermis. These burns appear pink or red, often accompanied by moisture and blister formation due to fluid leakage from damaged capillaries. They are painful because nerve endings remain intact. Healing occurs within 10 to 21 days without significant scarring.

Choice D Reason:Deep partial-thickness burns extend deeper into the dermis, damaging a larger portion of skin structures, including sweat glands and hair follicles. These burns typically appear red or white and may have a soft eschar (dead tissue), which differentiates them from more superficial burns that do not develop eschar. Unlike full-thickness burns, nerve endings remain partially intact, so the patient may still experience some pain. These burns take more than 21 days to heal and often require skin grafting to prevent complications such as contractures or hypertrophic scarring.

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The nurse provides instructions to a client diagnosed with inflammatory bowel syndrome (IBS) about measures to treat diarrhea caused by acute flare-ups. Which statement by the client indicates a need for further teaching?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

Correct Answer is D

Explanation

A client admitted with an acute exacerbation of Ménière's disease asks the student nurse why he was prescribed diphenhydramine. Which response by the student nurse requires correction by the primary nurse?

A client diagnosed with contact dermatitis is receiving education from the nurse. Which of the following therapies will the nurse recommend to the client?

A nurse is performing a focused assessment for vision on a client suspected of having vision loss. Which cranial nerve is the nurse assessing when determining if there are visual field or visual acuity deficits?

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following manifestations will the nurse expect to find? (Select all that apply.)

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

A nurse provides education to a client recently diagnosed with macular degeneration. Which of the following statements made by the client requires reinforcement of education by the nurse?

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

The nurse observes the client as he walks into the clinic. She notices a slight tremor of the hands, slowness of movements, and a mask-like facial expression, with postural instability. Which of the following in the client's history are consistent with these observations?