Ch 52

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder?

• Consuming too much fruit

• Consuming fried or pickled foods

• Consuming dairy products

• Consuming raw seafood

Answer explanation

Raw seafood is often contaminated and unless cooked can would most likely cause gastroenteritis. Any of the other food can also become contaminated if not stored properly or contaminated by workers/cooks who contaminate these foods.

The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse’s priority action?

• Low-fiber diet

• Skin protection

• Antibiotic administration

• Intravenous glucocorticoids

Answer explanation

Protecting the client’s skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn disease also includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

After teaching a client who has diverticulitis, a nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching?

• “I’ll ride my bike or take a long walk at least three times a week.”

• “I must try to include at least 25 g of fiber in my diet every day.”

• “I will take a laxative nightly at bedtime to avoid becoming constipated.”

• “I should use my legs rather than my back muscles when I lift heavy objects.”

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first?

• Inspection of oral mucosa

• Recent dietary intake

• Heart rate and rhythm

• Percussion of abdomen

Answer explanation

Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client would have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this patient than heart rate and rhythm.

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching?

“

• “I won’t let anyone use my dishes or glasses.”

• “I’ll wash my hands with antibacterial soap.”

• “I’ll keep my bathroom extra clean.”

• “I’ll cook all the meals for my family.”

Answer explanation

All of these statements are correct except for that the client should not prepare meals for others to help prevent transmission of gastroenteritis.