A patient with cholelithiasis is having clay-colored stools. What should the nurse realize as the most common cause of clay-colored stools?
a. Retrograde bile flow into the liver
b. Accumulation of bile salts in the skin
c. Cirrhosis from chronic liver irritation
d. A gallstone lodged in the common bile duct
ANS: D
Obstruction of bile flow (e.g., from a stone in the duct) may result in stools that are clay-colored, because bile is not present in the stool to give it color. A. B. C. Other liver and gallbladder disorders can also cause clay-colored stools, but in a patient with cholelithiasis, a stone lodged in the duct would be the most common.
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During a prenatal examination, a client asks, "How does my baby get air?" The nurse would give correct information by saying:
1. "The lungs of the fetus carry out respiratory gas exchange in utero." 2. "The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream." 3. "The blood from the placenta is carried through the umbilical artery, which penetrates the abdominal wall of the fetus." 4. "The fetus is able to obtain sufficient oxygen because your hemoglobin concentration is 50% greater during pregnancy."
When a client progresses to stage 5 renal disease, the nurse should conduct frequent nutritional assessments and provide education on the importance of an adequate nutritional intake to prevent:
1. Hyperglycemia. 2. Fat catabolism. 3. Hypertension. 4. Hyperlipidemia.
Shiny, hairless skin is an indication of
A) arterial problems in the feet and legs. B) poor venous return in the arms. C) the presence of blood clots. D) the presence of endocrine system disease.
When the nurse examines the patient and notes a fibroadenoma, which of the following questions is most appropriate?
A) How old are you? B) Have you had a referral for a biopsy? C) How long have you had a lump in your breast? D) Do you take birth control tablets?