Question

What clinical manifestations would a nurse expect to find in a client with celiac disease?

Answer 1

Correct Answers:

Chronic diarrhea and abdominal bloating

Rationale :

🌾 Celiac disease is an autoimmune disorder triggered by the ingestion of gluten, which damages the small intestinal mucosa and leads to malabsorption.

🌾 Common clinical manifestations include chronic diarrhea, abdominal bloating, flatulence, weight loss, and fatigue due to nutrient deficiencies.

🌾 The chronic diarrhea results from malabsorption of fats and other nutrients, while abdominal bloating is caused by excess gas production from poorly digested food.

🌾 Early recognition is important to prevent complications such as iron-deficiency anemia, osteoporosis, and growth delays in children.

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Answer 2

Correct Answers:

Instruct the patient to lay still during the procedure.

Rationale :

⚡ A nerve conduction study (NCS) measures how quickly and effectively electrical signals travel along a nerve.

⚡ To ensure accurate test results, the patient must remain still and relaxed during the procedure because movement can introduce artifacts or distort the electrical recordings.

⚡ Fasting is not required, hydration status does not affect the test, and deep breathing is not necessary since the study focuses on nerve and muscle response rather than respiratory function.

⚡ Proper positioning and stillness help the healthcare provider obtain clear, reliable measurements for accurate diagnosis of nerve disorders.

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Answer 3

Correct Answers:

Use of accessory muscles during breathing

Rationale :

💨 The use of accessory muscles (such as the sternocleidomastoid, scalene, and intercostal muscles) during breathing is an abnormal finding that indicates increased work of breathing and possible respiratory distress.

💨 This may occur in conditions like COPD, asthma exacerbations, pneumonia, or severe respiratory compromise.

💨 In a normal respiratory assessment, you would expect clear lung sounds, bilateral chest expansion, and a respiratory rate of 12–20 breaths per minute without visible labored effort.

💨 Detecting accessory muscle use early is important for timely intervention to prevent deterioration.

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Answer 4

Correct Answers:

Apply a cold compress to the site for the first 24 hours.

Rationale :

❄️ Arthrocentesis is a procedure in which synovial fluid is aspirated from a joint for diagnostic or therapeutic purposes.

❄️ Applying a cold compress to the site for the first 24 hours helps reduce swelling, pain, and inflammation caused by the procedure.

❄️ The joint should be rested, not kept in constant motion or subjected to vigorous activity, to allow proper healing and prevent complications.

❄️ Analgesics may be used as prescribed for pain relief, and clients should be instructed to monitor for signs of infection such as redness, warmth, or drainage.

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Answer 5

Correct Answers:

Edema

Rationale :

💧 Third spacing refers to the abnormal movement of fluid from the intravascular space into the interstitial or “third” space, where it is unavailable for normal physiological processes.

💧 A common symptom is edema, which can occur in areas such as the extremities, abdomen (ascites), or lungs (pulmonary edema).

💧 Third spacing can lead to hypovolemia despite the overall increase in total body fluid, often causing decreased urine output and hypotension—not increased urine output or hypertension.

💧 Weight gain, not weight loss, is more typical because of fluid accumulation.

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Answer 6

Correct Answers:

Activity intolerance related to decreased cardiac output

Rationale :

❤️ Cardiomyopathy is a disease of the heart muscle that impairs its ability to pump effectively, leading to decreased cardiac output.

❤️ This reduced output limits oxygen delivery to tissues, causing fatigue, weakness, and shortness of breath during even minimal physical activity—making activity intolerance the most appropriate nursing diagnosis.

❤️ Other options (fluid volume deficit, impaired skin integrity, imbalanced nutrition) may occur in different conditions, but they are not the primary, direct problem in cardiomyopathy unless complications develop.

❤️ The nursing focus is on energy conservation, gradual activity progression, and monitoring for signs of worsening heart failure during care.

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Answer 7

Correct Answers:

Administer oral antibiotics as prescribed.

Rationale :

💊 Sialadenitis is an inflammation or infection of the salivary glands, often caused by bacterial infection, with Staphylococcus aureus being a common pathogen.

💊 The primary treatment involves antibiotic therapy to eliminate the infection, alongside measures to promote salivary flow, such as adequate hydration, warm compresses, gentle massage, and sialogogues (e.g., lemon drops).

💊 While gentle massage can help in recovery, it is an adjunct measure—the priority nursing intervention is ensuring the infection is treated with antibiotics as prescribed.

💊 Cold compresses are generally less effective than warm compresses in this condition, and withholding food is unnecessary unless there is significant pain or difficulty swallowing.

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Answer 8

Correct Answers:

Electrolyte Imbalance

Rationale :

🩺 Acute pancreatitis is inflammation of the pancreas that can lead to significant fluid shifts and loss of electrolytes into the peritoneal cavity due to third spacing.

🩺 Common electrolyte imbalances include hypocalcemia (from fat saponification), hypokalemia, and hypomagnesemia, all of which can cause serious complications such as arrhythmias, muscle cramps, or seizures.

🩺 Monitoring and promptly correcting these imbalances is a priority in managing acute pancreatitis.

🩺 While DVT and pulmonary embolism are possible in severely ill patients, and cerebral aneurysm is unrelated, electrolyte imbalance is the most direct and common complication of acute pancreatitis.

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Answer 9

Correct Answers:

Serum potassium levels

Rationale :

🩺 Many diuretics—particularly loop diuretics (e.g., furosemide) and thiazide diuretics—cause increased excretion of potassium in the urine, leading to hypokalemia.

🩺 Hypokalemia can cause serious complications, including cardiac arrhythmias, muscle weakness, and fatigue, making potassium monitoring essential.

🩺 While sodium, magnesium, and calcium levels may also be affected, potassium changes occur most rapidly and can have life-threatening consequences if not corrected.

🩺 Nurses should also monitor for signs of low potassium and ensure the client receives supplementation if prescribed.

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Answer 10

Correct Answers:

Fluid overload

Rationale :

🌊 Fluid overload is a systemic complication of intravenous (IV) therapy that occurs when fluids are infused too rapidly or in excessive amounts, leading to an overload of the circulatory system.

🌊 Signs include hypertension, bounding pulse, distended neck veins, shortness of breath, and pulmonary edema.

🌊 This differs from local complications such as extravasation (leakage of vesicant solution), infiltration (non-vesicant leakage), and phlebitis (vein inflammation), which are confined to the IV site or surrounding tissue.

🌊 Prevention includes careful monitoring of infusion rates, assessing the client’s fluid status, and using infusion pumps when appropriate.

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Custom: N2100 Summer 25 Comprehensive Final

No.

1 :
What clinical manifestations would a nurse expect to find in a client with celiac disease?

2 :
A patient is scheduled for a nerve conduction study. As a nurse, which of the following interventions is most crucial to ensure accurate test results?

3 :
Which of the following findings would indicate an abnormality during the assessment of respiratory function in a patient?

4 :
Which of the following is an appropriate nursing intervention following an arthrocentesis procedure?

5 :
Which of the following is a common symptom of third spacing?

6 :
Which of the following is the most appropriate nursing diagnosis for a client with cardiomyopathy?

7 :
A patient is diagnosed with sialadenitis. Which nursing intervention is most appropriate to help alleviate the symptoms?

8 :
Which of the following is a potential complication for a patient with acute pancreatitis?

9 :
A client with fluid volume excess is prescribed a diuretic Which of the following should the nurse monitor closely in this client?

10 :
Which of the following is a common systemic complication associated with intravenous (IV) therapy?

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Custom: N2100 Summer 25 Comprehensive Final

No.

1 : What clinical manifestations would a nurse expect to find in a client with celiac disease?

2 : A patient is scheduled for a nerve conduction study. As a nurse, which of the following interventions is most crucial to ensure accurate test results?

3 : Which of the following findings would indicate an abnormality during the assessment of respiratory function in a patient?

4 : Which of the following is an appropriate nursing intervention following an arthrocentesis procedure?

5 : Which of the following is a common symptom of third spacing?

6 : Which of the following is the most appropriate nursing diagnosis for a client with cardiomyopathy?

7 : A patient is diagnosed with sialadenitis. Which nursing intervention is most appropriate to help alleviate the symptoms?

8 : Which of the following is a potential complication for a patient with acute pancreatitis?

9 : A client with fluid volume excess is prescribed a diuretic Which of the following should the nurse monitor closely in this client?

10 : Which of the following is a common systemic complication associated with intravenous (IV) therapy?

1 :
What clinical manifestations would a nurse expect to find in a client with celiac disease?

2 :
A patient is scheduled for a nerve conduction study. As a nurse, which of the following interventions is most crucial to ensure accurate test results?

3 :
Which of the following findings would indicate an abnormality during the assessment of respiratory function in a patient?

4 :
Which of the following is an appropriate nursing intervention following an arthrocentesis procedure?

5 :
Which of the following is a common symptom of third spacing?

6 :
Which of the following is the most appropriate nursing diagnosis for a client with cardiomyopathy?

7 :
A patient is diagnosed with sialadenitis. Which nursing intervention is most appropriate to help alleviate the symptoms?

8 :
Which of the following is a potential complication for a patient with acute pancreatitis?

9 :
A client with fluid volume excess is prescribed a diuretic Which of the following should the nurse monitor closely in this client?

10 :
Which of the following is a common systemic complication associated with intravenous (IV) therapy?