Detailed Answer Key GI/Neuro Med Surg 1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? A. Dextrose 5% in water Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water could cause rapid shifts in serum levels of some substances. B. 0.9% sodium chloride Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride could cause rapid shifts in serum levels of some substances. C. Dextrose 10% in water Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% or 20% in water until the next container of TPN solution arrives. D. Lactated Ringer’s solution Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution could cause rapid shifts in serum levels of some substances. 2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. “You should decrease your caloric intake when abdominal pain is present.” Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase their caloric intake in order to maintain weight. B. “You should increase your daily intake of protein.” Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein. C. “You should increase fat intake when experiencing loose stools.” Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent stimulation of the pancreas and steatorrhea. D. “You should limit alcohol intake to 2-3 drinks per week.” Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation of the pancreas. CAA_DetailedAnswerKey created 10/07/2015 page 1 of 53 Detailed Answer Key GI/Neuro Med Surg 3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness Rationale: Violent headache is correct. The client who manifests ICP should display a violent headache Neck pain and stiffness is incorrect. The client who manifests ICP should not display neck pain and stiffness Slurred speech is correct. The client who manifests ICP may display slurred speech. Projectile vomiting is correct. The client who manifests ICP may display sudden onset of projectile vomiting. Rapid loss of consciousness is correct. The client who manifests ICP may display a sudden rapid loss of consciousness. CAA_DetailedAnswerKey created 10/07/2015 page 2 of 53 Detailed Answer Key GI/Neuro Med Surg 4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe headache Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation. B. Bradycardia Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not bradycardia. C. Increased muscle tone Rationale: The nurse should find as a sign of meningococcal meningitis decreased not increased muscle tone. D. Oriented to time, person, place Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not orientation to time, person, and place. 5. A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a manifestation considered an early indication of increased intracranial pressure (ICP) is A. bradycardia. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. B. ipsilateral pupil dilation. Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure displaces the brain against the optic nerve, but pupil dilation is not an early sign of increased ICP. C. widening pulse pressure. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. D. lethargy. Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. An early sign of increasing ICP is lethargy. CAA_DetailedAnswerKey created 10/07/2015 page 3 of 53 Detailed Answer Key GI/Neuro Med Surg 6. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed? A. NPO until dysphagia subsides Rationale: Making the client NPO provides no nutritional support and will not likely be prescribed. B. Supplements via nasogastric tube Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed. C. Initiation of total parenteral nutrition Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the ingestion, digestion, and absorption of essential nutrients. This nutritional therapy will not likely be prescribed.