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Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 10 Inflammation
The Concept of Inflammation
1) The nurse is caring for a client who has experienced a sports-related injury to the knee. During
the morning assessment, which signs of inflammation does the nurse anticipate?
Select all that apply.
A) Pitting edema
B) Pallor
C) Swelling
D) Warmth
E) Pain
Answer: C, D, E
Explanation: A) Swelling, warmth, and pain are signs of inflammation. Pallor is not a sign of
inflammation; redness is. Pitting edema is not a sign of inflammation.
B) Swelling, warmth, and pain are signs of inflammation. Pallor is not a sign of inflammation;
redness is. Pitting edema is not a sign of inflammation.
C) Swelling, warmth, and pain are signs of inflammation. Pallor is not a sign of inflammation;
D) Swelling, warmth, and pain are signs of inflammation. Pallor is not a sign of inflammation;
E) Swelling, warmth, and pain are signs of inflammation. Pallor is not a sign of inflammation;
Page Ref: 637
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the inflammatory process.
QSEN Competencies: III.A.1 Demonstrate knowledge of basic scientific methods and processes
AACN Essential Competencies: IX.3 Implement holistic, patient-centered care that reflects an
understanding of human growth and development, pathophysiology, pharmacology, medical
management and nursing management across the health-illness continuum, across lifespan, and
in all healthcare settings
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and
quality and safe patient care
MNL Learning Outcome: 10.1.1 Understand the physiology of inflammation across the life span.
1
Copyright © 2015 Pearson Education, Inc.
2) A client is admitted with airway edema, bronchoconstriction, and increased mucus production
after being exposed to an allergen. Which nursing interventions are appropriate to address this
inflammation to the respiratory system?
A) Turn and reposition every 2 hours.
B) Monitor oxygen saturation.
C) Administer oxygen as prescribed.
D) Restrict fluids.
E) Monitor lung sounds.
Answer: B, C, E
Explanation: A) Turning and repositioning every 2 hours would be appropriate to maintain
tissue integrity. Monitoring oxygen saturation, administering oxygen, and monitoring lung
sounds would be appropriate care for the client with inflammation to the respiratory system.
Restricting fluids could cause respiratory secretions to thicken and hinder the client's ability to
maintain a clear airway. Fluids should be encouraged.
B) Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity.
Monitoring oxygen saturation, administering oxygen, and monitoring lung sounds would be
appropriate care for the client with inflammation to the respiratory system. Restricting fluids
could cause respiratory secretions to thicken and hinder the client's ability to maintain a clear
airway. Fluids should be encouraged.
C) Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity.
D) Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity.
E) Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity.
Page Ref: 638
Client Need Sub: Reduction of Risk Potential
Nursing Process: Implementation
Learning Outcome: 2. Examine the relationship between inflammation and other
concepts/systems.
2
MNL Learning Outcome: 10.1.2 Compare common alterations across the life span, concepts
related to inflammation, and prevention.
3
3) The nurse is providing instructions to a client who is prescribed a nonsteroidal anti-
inflammatory drug (NSAID). Which information is priority for the nurse to explain to the client
about this medication?
A) "Take your medication on an empty stomach."
B) "Drink at least 8-10 glasses of water a day while taking your medication."
C) "Constipation is common with your medication; include roughage in your diet."
D) "Take your medication with food."
Answer: B
Explanation: A) Nonsteroidal anti-inflammatory drugs (NSAIDS) are nephrotoxic; keeping the
client well hydrated will help prevent kidney damage. Taking the medication with food will
decrease gastrointestinal (GI) irritation, but preventing kidney damage is more of a priority.
Taking the medication on an empty stomach will increase gastrointestinal (GI) irritation.
Constipation is not an issue with NSAIDs.
B) Nonsteroidal anti-inflammatory drugs (NSAIDS) are nephrotoxic; keeping the client well
hydrated will help prevent kidney damage. Taking the medication with food will decrease
gastrointestinal (GI) irritation, but preventing kidney damage is more of a priority. Taking the
medication on an empty stomach will increase gastrointestinal (GI) irritation. Constipation is not
an issue with NSAIDs.
C) Nonsteroidal anti-inflammatory drugs (NSAIDS) are nephrotoxic; keeping the client well
D) Nonsteroidal anti-inflammatory drugs (NSAIDS) are nephrotoxic; keeping the client well
Page Ref: 643
Client Need Sub: Pharmacological and Parenteral Therapies
Learning Outcome: 3. Identify commonly occurring alterations in inflammatory and their related
treatments.
4
4) The nurse is caring for a client with severe inflammation. Which assessment findings would
indicate a systemic reaction to inflammation?
A) Erythema
B) Edema
C) Pain
D) Tachypnea
E) Tachycardia
Answer: D, E
Explanation: A) If the nurse observes a systemic reaction, the client will exhibit manifestations
including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain,
edema, and functional impairment indicate a local reaction.
B) If the nurse observes a systemic reaction, the client will exhibit manifestations including
temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and
functional impairment indicate a local reaction.
C) If the nurse observes a systemic reaction, the client will exhibit manifestations including
D) If the nurse observes a systemic reaction, the client will exhibit manifestations including
E) If the nurse observes a systemic reaction, the client will exhibit manifestations including
Page Ref: 639
Cognitive Level: Analyzing
Learning Outcome: 4. Differentiate common assessment procedures used to examine the
inflammatory process across the life span.
QSEN Competencies: 1.A.1 Integrate understanding of multiple dimensions of patient centered

care:
o patient/family/community preferences, values
o coordination and integration of care
o information, communication, and education
o physical comfort and emotional support
o involvement of family and friends
o transition and continuity
5
MNL Learning Outcome: 10.1.3 Identify procedures used to determine inflammation status
across the life span.
6
5) The nurse in a rheumatology clinic is managing care for clients who receive nonsteroidal anti-
inflammatory drugs (NSAIDs) for the treatment of their disease processes. Which are the
primary laboratory tests the nurse will assess prior to initiation of this type of therapy?
A) Serum amylase
B) Electrolytes
C) Creatine clearance
D) Complete blood count (CBC)
E) Liver function tests
Answer: C, D, E
Explanation: A) It is important to assess the client's creatine clearance to determine kidney
function prior to initiation of nonsteroidal anti-inflammatory drug (NSAID) therapy. It is also
important to assess the client's liver function tests and complete blood count (CBC) prior to
initiation of NSAID therapy. There is no need to assess the client's electrolytes or serum
amylase; these are not factors that are affected by NSAIDs.
B) It is important to assess the client's creatine clearance to determine kidney function prior to
initiation of nonsteroidal anti-inflammatory drug (NSAID) therapy. It is also important to assess
the client's liver function tests and complete blood count (CBC) prior to initiation of NSAID
therapy. There is no need to assess the client's electrolytes or serum amylase; these are not
factors that are affected by NSAIDs.
C) It is important to assess the client's creatine clearance to determine kidney function prior to
D) It is important to assess the client's creatine clearance to determine kidney function prior to
E) It is important to assess the client's creatine clearance to determine kidney function prior to
Page Ref: 641
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
inflammatory process status.
7
MNL Learning Outcome: 10.1.3 Identify procedures used to determine inflammation status
8
6) The nurse is providing care to a client who experiences chronic inflammation due to arthritis.
Which collaborative intervention does the nurse plan for when providing care to this client?
A) Administering anti-inflammatory medications
B) Administering diuretics
C) Administering frequent doses of opioid medications
D) Administering antibiotics
Answer: A
Explanation: A) Anti-inflammatory medication will reduce the pain and inflammation caused by
arthritis. Opioid medication is not usually indicated to treat a chronic inflammatory process.
Antibiotics would be ordered for an infection, not chronic inflammation. Diuretics are not used
to treat the inflammatory process.
B) Anti-inflammatory medication will reduce the pain and inflammation caused by arthritis.
Opioid medication is not usually indicated to treat a chronic inflammatory process. Antibiotics
would be ordered for an infection, not chronic inflammation. Diuretics are not used to treat the
inflammatory process.
C) Anti-inflammatory medication will reduce the pain and inflammation caused by arthritis.
D) Anti-inflammatory medication will reduce the pain and inflammation caused by arthritis.
Page Ref: 643
Nursing Process: Planning
Learning Outcome: 6. Explain management of the inflammatory process and prevention of
inflammation.

care:
9
10
7) The nurse is caring for a client from India who has extensive deep tissue damage. The nurse
notes that the client is also vegan. Which dietary information should the nurse teach this client to
enhance the healing process?
A) "A low-fat, high-carbohydrate, low-protein diet is best for healing."
B) "A high-fat, low-carbohydrate diet is best for healing."
C) "A high-carbohydrate, high-protein diet is best for healing."
D) "A diet high in protein and vitamin D is best for healing."
Answer: C
Explanation: A) Carbohydrates are important to meet the energy demands of healing, and
protein is needed is needed for cell growth. The vegan client needs to be taught to eat proteins
that provide the essential amino acids that can be lacking in a vegan diet. Fats are needed in
moderation for the development of cell membranes. Vitamins necessary to promote healing are
C, K, A, and the B-complex vitamins.
B) Carbohydrates are important to meet the energy demands of healing, and protein is needed is
needed for cell growth. The vegan client needs to be taught to eat proteins that provide the
essential amino acids that can be lacking in a vegan diet. Fats are needed in moderation for the
development of cell membranes. Vitamins necessary to promote healing are C, K, A, and the B-
complex vitamins.
C) Carbohydrates are important to meet the energy demands of healing, and protein is needed is
complex vitamins.
D) Carbohydrates are important to meet the energy demands of healing, and protein is needed is
complex vitamins.
Page Ref: 642
Client Need Sub: Basic Care and Comfort
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in the

care:
11
MNL Learning Outcome: 10.1.4 Explain independent and collaborative interventions for clients
with alterations in inflammation.
12
8) The nurse instructs an older adult client with arthritis on the side effects of nonsteroidal anti-
inflammatory drug (NSAID) therapy. Which client statement would indicate that teaching had
been effective?
A) "I will report any abnormal bruising."
B) "Caffeine will decrease the effectiveness of the medication."
C) "I cannot take other medications."
D) "If I have a change in my mood I will call the prescriber."
Answer: A
Explanation: A) Older adult clients are at risk for increased bleeding with nonsteroidal anti-
inflammatory drug (NSAID) therapy. The client should be taught to report any abnormal
bruising, which may indicate bleeding. Older adult clients often take several medications, and
refraining from taking them with NSAIDs is an unrealistic outcome. Mood changes are not a side
effect of NSAID therapy. There is no reason for avoiding use of caffeine while using an NSAID.
B) Older adult clients are at risk for increased bleeding with nonsteroidal anti-inflammatory drug
(NSAID) therapy. The client should be taught to report any abnormal bruising, which may
indicate bleeding. Older adult clients often take several medications, and refraining from taking
them with NSAIDs is an unrealistic outcome. Mood changes are not a side effect of NSAID
therapy. There is no reason for avoiding use of caffeine while using an NSAID.
C) Older adult clients are at risk for increased bleeding with nonsteroidal anti-inflammatory drug
D) Older adult clients are at risk for increased bleeding with nonsteroidal anti-inflammatory drug
Page Ref: 643
Nursing Process: Evaluation
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in the inflammatory process.

care:
13
MNL Learning Outcome: 10.1.4 Explain independent and collaborative interventions for clients
with alterations in inflammation.
14
Exemplar 10.1 Appendicitis
1) A client is admitted to the hospital with an elevated temperature, nausea, and pain and
tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the
client continues to complain of pain at a level of 8 on a 1-10 pain scale. Pain medications are not
due for at least another 2 hours. Which statement by the nurse is appropriate?
A) "I will inform the healthcare provider about your continued pain."
B) "I do not have any medications ordered for you at this time."
C) "Try to rest for a while longer until it is time to receive your medication"
D) "Let's try a heating pad or warm blanket to see if that helps with your discomfort."
Answer: A
Explanation: A) The client's inability to achieve comfort will need to be reported to the
physician. The reported manifestations are consistent with appendicitis and the client is at risk
for perforation, which is manifested by increased pain. The use of heat to manage the pain is
contraindicated due to the risk of perforation. Advising the client that no medications are
available at this time and encouraging rest do not meet the concerns being presented by the
client.
B) The client's inability to achieve comfort will need to be reported to the physician. The
reported manifestations are consistent with appendicitis and the client is at risk for perforation,
which is manifested by increased pain. The use of heat to manage the pain is contraindicated due
to the risk of perforation. Advising the client that no medications are available at this time and
encouraging rest do not meet the concerns being presented by the client.
C) The client's inability to achieve comfort will need to be reported to the physician. The
D) The client's inability to achieve comfort will need to be reported to the physician. The
Page Ref: 643
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of appendicitis.
15
MNL Learning Outcome: 10.2.1 Differentiate the pathophysiology, etiology, risk factors,
prevention, and clinical manifestations.
16
2) A client with acute abdominal pain is scheduled for an appendectomy in 3 hours. While
waiting for the surgery, the client reports that the pain has subsided. Which is the priority action
by the nurse?
A) Determine when the client can be medicated for pain.
B) Contact the surgery department.
C) Contact the healthcare provider.
D) Notify the nursing supervisor.
Answer: C
Explanation: A) The pain relief being experienced by the client is consistent with rupture of the
appendix. The healthcare provider should be notified. If the appendix has ruptured, the risk of
peritonitis will increase. The next time the client can be medicated for pain is not relevant for this
client. Notification of the surgery department and the nursing supervisor should not be completed
before contact with the healthcare provider.
B) The pain relief being experienced by the client is consistent with rupture of the appendix. The
healthcare provider should be notified. If the appendix has ruptured, the risk of peritonitis will
increase. The next time the client can be medicated for pain is not relevant for this client.
Notification of the surgery department and the nursing supervisor should not be completed
C) The pain relief being experienced by the client is consistent with rupture of the appendix. The
D) The pain relief being experienced by the client is consistent with rupture of the appendix. The
Page Ref: 646
Cognitive Level: Understanding
Learning Outcome: 2. Identify risk factors and prevention methods associated with appendicitis.
17
3) The adult female Iranian client develops signs and symptoms of appendicitis during the night.
The client is brought to the emergency department by family. Which nursing intervention is the
most culturally sensitive for this client?
A) Ask the healthcare provider which one should see the client.
B) Ask for a female healthcare provider to assess the client.
C) Ask for a male healthcare provider to assess the client.
D) Explain the assessment procedure and ask the family their preference.
Answer: D
Explanation: A) Culturally competent care means collaborating with the client to determine the
client's preferences for medical care. The nurse should not assume that a foreign client will want
a male or female doctor. Asking the healthcare providers to decide does not include the client's
wishes.
B) Culturally competent care means collaborating with the client to determine the client's
preferences for medical care. The nurse should not assume that a foreign client will want a male
or female doctor. Asking the healthcare providers to decide does not include the client's wishes.
C) Culturally competent care means collaborating with the client to determine the client's
D) Culturally competent care means collaborating with the client to determine the client's
Page Ref: 646
Client Need: Psychosocial Integrity
Client Need Sub:
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with appendicitis.
QSEN Competencies: I.A.1 Integrate understanding of multiple dimensions of patient centered

care:
MNL Learning Outcome: 10.2.3 Apply the nursing process to provide culturally competent care
18
19
4) The nurse is caring for a pediatric client recovering from surgery for a perforated appendix.
Which nursing diagnosis should the nurse use to guide this client's care during the immediate
postoperative period?
A) Risk for Chronic Pain
B) Risk for Impaired Perfusion
C) Risk for Deficient Fluid Volume
D) Risk for Infection
Answer: D
Explanation: A) Since the client is recovering from an appendectomy, the client will most likely
have acute pain. There is no evidence to suggest the client is at risk for impaired perfusion or
deficient fluid volume. Because the appendix ruptured before surgery, the client is at risk for
infection, specifically peritonitis.
B) Since the client is recovering from an appendectomy, the client will most likely have acute
pain. There is no evidence to suggest the client is at risk for impaired perfusion or deficient fluid
volume. Because the appendix ruptured before surgery, the client is at risk for infection,
specifically peritonitis.
C) Since the client is recovering from an appendectomy, the client will most likely have acute
D) Since the client is recovering from an appendectomy, the client will most likely have acute
Page Ref: 647
Nursing Process: Diagnosis
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
appendicitis.

care:
20
21
5) The nurse, caring for older school-age client recovering from an appendectomy, is preparing
to help the family ambulate the child for the first time after surgery. Which non-pharmacological
nursing strategy would be appropriate for this client?
A) A warm, moist pack over the site of the incision
B) A splint pillow against the abdomen when moving or coughing
C) Administering appropriate narcotic analgesics
D) An ice pack over the site of the incision
Answer: B
Explanation: A) A splint pillow placed on the abdomen is a non-pharmacological strategy to
decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as
they can impair the healing process of the wound. Administering a narcotic is considered a
pharmacological nursing strategy.
B) A splint pillow placed on the abdomen is a non-pharmacological strategy to decrease
discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can
impair the healing process of the wound. Administering a narcotic is considered a
C) A splint pillow placed on the abdomen is a non-pharmacological strategy to decrease
D) A splint pillow placed on the abdomen is a non-pharmacological strategy to decrease
Page Ref: 647
Learning Outcome: 6. Plan evidence-based care for an individual with appendicitis and his or
her family in collaboration with other members of the healthcare team.
QSEN Competencies: III.A.2 Describe EBP to include the components of research evidence,
clinical expertise and patient/family values.
MNL Learning Outcome: 10.2.2 Identify collaborative therapies used by interdisciplinary teams.
22
6) A client with appendicitis is highly agitated and states that there is a great deal of pain. Which
intervention will decrease the client's anxiety?
A) Assess pain levels every 2 hours and administer ordered medication.
B) Provide reading material to help distract the client.
C) Distract the client with ambulation.
D) Administer pain medications when the client complains of pain.
Answer: A
Explanation: A) The extreme pain experienced by the client with appendicitis is the source of
the client's anxiety. Assessing pain levels every 2 hours and administering medications before
the pain gets intense is the best intervention for anxiety. Waiting until the client complains of
pain makes pain relief more difficult and increases anxiety. Distraction does not work when
clients have severe pain but is more appropriate for those with chronic pain.
B) The extreme pain experienced by the client with appendicitis is the source of the client's
anxiety. Assessing pain levels every 2 hours and administering medications before the pain gets
intense is the best intervention for anxiety. Waiting until the client complains of pain makes pain
relief more difficult and increases anxiety. Distraction does not work when clients have severe
pain but is more appropriate for those with chronic pain.
C) The extreme pain experienced by the client with appendicitis is the source of the client's
D) The extreme pain experienced by the client with appendicitis is the source of the client's
Page Ref: 647
Learning Outcome: 7. Evaluate expected outcomes for an individual with appendicitis.

care:
23
24
7) The nurse is caring for a client in the emergency department who is suspected of having
appendicitis. Based on this data, which prescriptions does the nurse anticipate from the
healthcare provider?
A) A cephalosporin
B) A barium enema
C) Regular diet
D) Pain medication
E) Complete white blood cell count
Answer: A, D, E
Explanation: A) Pain medications will be ordered as will a complete white blood count, which
will be elevated. A barium enema is not ordered, as this could cause perforation of the appendix
and bowel. The client will take nothing by mouth, and the cephalosporins are the antibiotic of
choice for antibiotic therapy.
B) Pain medications will be ordered as will a complete white blood count, which will be
elevated. A barium enema is not ordered, as this could cause perforation of the appendix and
bowel. The client will take nothing by mouth, and the cephalosporins are the antibiotic of choice
for antibiotic therapy.
C) Pain medications will be ordered as will a complete white blood count, which will be
D) Pain medications will be ordered as will a complete white blood count, which will be
E) Pain medications will be ordered as will a complete white blood count, which will be
Page Ref: 646
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with appendicitis.
QSEN Competencies: I.A.1 Demonstrate knowledge of basic scientific methods and processes
25
8) The nurse is conducting an assessment on a client who is 36 hours postoperative following an
appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client
denies passing flatus. Which action is most appropriate by the nurse?
A) Withholding food and fluid intake until intestinal motility has returned
B) Encouraging the client to increase fluid intake to promote peristalsis
C) Encouraging the client to increase solid food intake to promote peristalsis
D) Encouraging the client to decrease the amount of oral intake
Answer: A
Explanation: A) After abdominal surgery, the risk of a paralytic ileus exists. An ileus results
when the bowel is not experiencing peristalsis. Oral intake must be withheld during this time.
B) After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is
not experiencing peristalsis. Oral intake must be withheld during this time.
C) After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel is
not experiencing peristalsis. Oral intake must be withheld during this time.
D) After abdominal surgery, the risk of a paralytic ileus exists. An ileus results when the bowel
is not experiencing peristalsis. Oral intake must be withheld during this time.
Page Ref: 647
Learning Outcome: 6. Plan evidence-based care for an individual with appendicitis and his or
her family in collaboration with other members of the healthcare team.
26
9)
A nurse checking for tenderness at McBurney's point for a client with suspected appendicitis will
palpate which area?
A) A
B) B
C) C
D) D
Answer: C
Explanation: A) McBurney's point, located midway between the umbilicus and the anterior iliac
crest in the right lower quadrant, is the usual side for localized pain and rebound tenderness due
to appendicitis.
B) McBurney's point, located midway between the umbilicus and the anterior iliac crest in the
right lower quadrant, is the usual side for localized pain and rebound tenderness due to
appendicitis.
C) McBurney's point, located midway between the umbilicus and the anterior iliac crest in the
appendicitis.
D) McBurney's point, located midway between the umbilicus and the anterior iliac crest in the
appendicitis.
Page Ref: 645
across the life span for individuals with appendicitis.

care:
27
28
10) List the pathophysiology processes involved in appendicitis in sequential order.
A) The appendix becomes distended with fluid secreted by its mucosa.
B) Obstruction of the proximal lumen of the appendix is apparent.
C) Purulent exudate formed causes further distention of the appendix.
D) Pressure within the lumen of the appendix increases.
E) Tissue necrosis and gangrene result.
Answer: B, A, D, C, E
Explanation: A) Obstruction of the proximal lumen of the appendix is apparent in most acutely
inflamed appendices. Following obstruction, the appendix becomes distended with fluid secreted
by its mucosa. Pressure within the lumen of the appendix increases, impairs its blood supply, and
leads to inflammation, edema, ulceration, and infection. The purulent exudate formed causes
further distention of the appendix. If treatment is not initiated, tissue necrosis and gangrene result
within 24-36 hours, leading to perforation (rupture).
B) Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed
appendices. Following obstruction, the appendix becomes distended with fluid secreted by its
mucosa. Pressure within the lumen of the appendix increases, impairs its blood supply, and leads
to inflammation, edema, ulceration, and infection. The purulent exudate formed causes further
distention of the appendix. If treatment is not initiated, tissue necrosis and gangrene result within
24-36 hours, leading to perforation (rupture).
C) Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed
D) Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed
E) Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed
Page Ref: 644
direct and indirect causes of appendicitis.
29
30
Exemplar 10.2 Gallbladder Disease
1) The nurse is caring for a client who was admitted to the hospital 1 day prior with
cholelithiasis. Which new assessment finding indicates the stone has probably obstructed the
common bile duct?
A) Nausea and vomiting
B) Jaundice
C) Right upper quadrant (RUQ) pain
D) Elevated cholesterol level
Answer: B
Explanation: A) Nausea and RUQ pain occur in cystic duct disease, but obstruction of the
common bile duct results in reflux of bile into the liver, which produces jaundice. Cholesterol
levels do not increase with biliary obstruction.
B) Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct
results in reflux of bile into the liver, which produces jaundice. Cholesterol levels do not increase
with biliary obstruction.
C) Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct
D) Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct
Page Ref: 650
direct and indirect causes of gallbladder disease.
31
2) The nurse is caring for an older adult client with gallbladder disease recovering from a
cholecystectomy. Which risk factors increase this client's susceptibility to infection?
A) Dry skin
B) Advanced age
C) Intact mucous membranes
D) Non-intact skin
E) Active bowel sounds
Answer: B, D
Explanation: A) This client is more susceptible to infection due to an advanced age and a
surgical incision. A surgical incision indicates that the first line of defense, the skin, is not intact.
Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the
body against infection.
B) This client is more susceptible to infection due to an advanced age and a surgical incision. A
surgical incision indicates that the first line of defense, the skin, is not intact. Active bowel
sounds, dry skin, and intact mucous membranes are factors that help defend the body against
infection.
C) This client is more susceptible to infection due to an advanced age and a surgical incision. A
infection.
D) This client is more susceptible to infection due to an advanced age and a surgical incision. A
infection.
E) This client is more susceptible to infection due to an advanced age and a surgical incision. A
infection.
Page Ref: 654
Learning Outcome: 2. Identify risk factors and prevention methods associated with gallbladder
disease.
32
3) The nurse educator in a gastrostomy clinic is teaching a group of clients about how nutrition
plays a role in the formation of gallstones. Which client would the nurse expect to benefit the
most from this teaching session?
A) The Native American client
B) The African-American client
C) The Asian client
D) The Norwegian client
Answer: A
Explanation: A) Native Americans have a higher incidence of gallstones than Asians,
Caucasians, and African-Americans. This is believed to result from genes that promote
inefficient calorie use and fat storage.
B) Native Americans have a higher incidence of gallstones than Asians, Caucasians, and
African-Americans. This is believed to result from genes that promote inefficient calorie use and
fat storage.
C) Native Americans have a higher incidence of gallstones than Asians, Caucasians, and
fat storage.
D) Native Americans have a higher incidence of gallstones than Asians, Caucasians, and
fat storage.
Page Ref: 650-651
Client Need: Health Promotion and Maintenance
Client Need Sub:
Learning Outcome: 2. Identify risk factors and prevention methods associated with gall bladder
disease.
33
4) The nurse is caring for an older adult client with cholecystitis. The client has been admitted to
the hospital for diagnostic testing and pain control. Which nursing diagnosis would be a priority
for this client?
A) Anxiety
B) Risk for Infection
C) Impaired Comfort
D) Imbalanced Nutrition: Less than Body Requirements
Answer: B
Explanation: A) All of these diagnoses are appropriate for the client with gallbladder disease.
However, because the elderly client does not have as effective an immune system as younger
clients, the nurse should prioritize care around preventing infection in this client.
B) All of these diagnoses are appropriate for the client with gallbladder disease. However,
because the elderly client does not have as effective an immune system as younger clients, the
nurse should prioritize care around preventing infection in this client.
C) All of these diagnoses are appropriate for the client with gallbladder disease. However,
D) All of these diagnoses are appropriate for the client with gallbladder disease. However,
Page Ref: 654
Nursing Process: Diagnosis
gallbladder disease.

care:
34
5) A client who is 4 days post-cholecystectomy has T-tube drainage totaling 600 mL in 24 hours.
Which actions by the nurse are appropriate based on this data?
A) Notify the healthcare provider.
B) Place the client in a supine position.
C) Assess drainage characteristics.
D) Clamp the tube q 2 hours for 30 minutes.
E) Encourage an increased fluid intake.
Answer: A, C
Explanation: A) The T-tube may drain 500 mL in the first 24 hours and is expected to decrease
steadily thereafter. If there is excessive drainage, the nurse should further assess the drainage to
be able to describe it accurately and notify the healthcare provider immediately. Clamping the
tube would be contraindicated. Placing the client in a supine position and encouraging fluid
intake are of no help.
B) The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily
thereafter. If there is excessive drainage, the nurse should further assess the drainage to be able to
describe it accurately and notify the healthcare provider immediately. Clamping the tube would
be contraindicated. Placing the client in a supine position and encouraging fluid intake are of no
help.
C) The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily
help.
D) The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily
help.
E) The T-tube may drain 500 mL in the first 24 hours and is expected to decrease steadily
help.
Page Ref: 652
Learning Outcome: 6. Plan evidence-based care for an individual with gallbladder disease and
his or her family in collaboration with other members of the healthcare team.
35
36
6) The nurse is evaluating care provided to an older adult client with a history of cholecystitis 5
months ago. Which statement indicates the client met a goal in the plan of care?
A) "I have increased my intake of fat."
B) "I have been eating out often."
C) "I have been walking 1 mile every day."
D) "I have been able to gain 5 pounds on the new diet."
Answer: D
Explanation: A) The older adult client with cholecystitis is at risk for infection. A goal would be
to stabilize or increase weight through the appropriate diet to support the immune system and
resist infection. Exercise is excellent but does not meet this client's goal. Eating out would not be
a goal for a client being treated for cholecystitis. The client would want to decrease fat intake.
B) The older adult client with cholecystitis is at risk for infection. A goal would be to stabilize or
increase weight through the appropriate diet to support the immune system and resist infection.
Exercise is excellent but does not meet this client's goal. Eating out would not be a goal for a
client being treated for cholecystitis. The client would want to decrease fat intake.
C) The older adult client with cholecystitis is at risk for infection. A goal would be to stabilize or
D) The older adult client with cholecystitis is at risk for infection. A goal would be to stabilize or
Page Ref: 655
Learning Outcome: 7. Evaluate expected outcomes for an individual with gallbladder disease.

care:
37
38
7) The nurse is caring for a client newly admitted to the hospital with uncomplicated
cholelithiasis. Based on this data, which laboratory value does the nurse anticipate to be
elevated?
A) Mean corpuscular hemoglobin concentration (MCHC)
B) Indirect bilirubin
C) Serum amylase
D) Alkaline phosphatase
Answer: D
Explanation: A) Obstructive biliary disease causes a significant elevation in alkaline
phosphatase. Obstruction in the biliary tract causes an elevation in direct bilirubin, not indirect
bilirubin. The client's serum amylase and MCHC are unrelated.
B) Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Obstruction
in the biliary tract causes an elevation in direct bilirubin, not indirect bilirubin. The client's serum
amylase and MCHC are unrelated.
C) Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Obstruction
D) Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Obstruction
Page Ref: 651
care of an individual with gallbladder disease.
39
8) A client with cholelithiasis is in the clinic for a follow-up assessment following
hospitalization. What lifestyle modification should the nurse teach the client to decrease the pain
associated with the disease process?
A) Reduce sodium intake
B) Decrease fat consumption
C) Increase fluids
D) Decrease smoking
Answer: B
Explanation: A) The client who is experiencing cholelithiasis should be instructed on the
relationship between increased fat consumption and the severity of pain associated with
cholelithiasis. While all clients should be instructed to reduce sodium intake, decreasing sodium
will not assist in reducing cholelithiasis or its pain. Increasing fluids will not assist in reducing
cholelithiasis or its pain. While all clients should cease smoking, it has no relationship to
cholelithiasis.
B) The client who is experiencing cholelithiasis should be instructed on the relationship between
increased fat consumption and the severity of pain associated with cholelithiasis. While all
clients should be instructed to reduce sodium intake, decreasing sodium will not assist in
reducing cholelithiasis or its pain. Increasing fluids will not assist in reducing cholelithiasis or its
pain. While all clients should cease smoking, it has no relationship to cholelithiasis.
C) The client who is experiencing cholelithiasis should be instructed on the relationship between
D) The client who is experiencing cholelithiasis should be instructed on the relationship between
Page Ref: 655
Client Need Sub:
Learning Outcome: 2. Identify risk factors and prevention methods associated with gall bladder
disease.
40
9) A nurse is caring for a client with severe acute abdominal pain secondary to cholelithiasis.
Which nursing actions promote effective pain management?
A) Withhold oral food and fluids.
B) Insert nasogastric tube and connect to high wall suction.
C) Educate the client about decreasing protein in the diet, as protein increases gallbladder
contractions.
D) Administer morphine, meperidine, or another opioid analgesic as ordered.
E) Place the patient in supine position to relieve abdominal pain.
Answer: A, D
Explanation: A) The pain associated with cholelithiasis can be severe. Nursing interventions that
help to promote effective pain management include withholding oral food and fluids and
inserting a nasogastric tube connected to low wall suction. The nurse should educate the client
about decreasing fat in the diet, as fat entering the duodenum initiates gallbladder contractions,
causing pain when gallstones are in the ducts. Administering morphine, meperidine, or another
opioid analgesic as ordered aids in pain management. The nurse should place the patient in
Fowler position, not supine, to decrease pressure on the inflamed gallbladder.
B) The pain associated with cholelithiasis can be severe. Nursing interventions that help to
promote effective pain management include withholding oral food and fluids and inserting a
nasogastric tube connected to low wall suction. The nurse should educate the client about
decreasing fat in the diet, as fat entering the duodenum initiates gallbladder contractions, causing
pain when gallstones are in the ducts. Administering morphine, meperidine, or another opioid
analgesic as ordered aids in pain management. The nurse should place the patient in Fowler
position, not supine, to decrease pressure on the inflamed gallbladder.
C) The pain associated with cholelithiasis can be severe. Nursing interventions that help to
D) The pain associated with cholelithiasis can be severe. Nursing interventions that help to
41
E) The pain associated with cholelithiasis can be severe. Nursing interventions that help to
Page Ref: 654
across the life span for individuals with gallbladder disease.

care:
42
Exemplar 10.3 Inflammatory Bowel Disease
1) An adolescent client is experiencing abdominal pain with diarrhea and bloody stools. Based
on this data, which specific type of inflammatory bowel disease does the nurse suspect the client
is experiencing?
A) Appendicitis
B) Ulcerative colitis
C) Crohn's disease
D) Necrotizing enterocolitis
Answer: B
Explanation: A) Diarrhea and bloody stools are typical symptoms of ulcerative colitis.
Appendicitis is not associated with bloody stools, and usually not with diarrhea. The teen with
Crohn disease might have abdominal pain and diarrhea, but stools usually do not have blood in
them. Necrotizing enterocolitis is usually seen in premature infants and not generally in an
adolescent client.
B) Diarrhea and bloody stools are typical symptoms of ulcerative colitis. Appendicitis is not
associated with bloody stools, and usually not with diarrhea. The teen with Crohn disease might
have abdominal pain and diarrhea, but stools usually do not have blood in them. Necrotizing
enterocolitis is usually seen in premature infants and not generally in an adolescent client.
C) Diarrhea and bloody stools are typical symptoms of ulcerative colitis. Appendicitis is not
D) Diarrhea and bloody stools are typical symptoms of ulcerative colitis. Appendicitis is not
Page Ref: 657
direct and indirect causes of inflammatory bowel disease (IBD).
43
2) The nurse is caring for an adolescent client who has been non-adherent with the medical plan
of care to treat Crohn disease. In order to increase adherent behavior, which complication
associated with Crohn disease will the nurse include in the client’s teaching plan?
A) Vomiting
B) Bowel perforation
C) Intestinal obstruction
D) Diarrhea
Answer: B
Explanation: A) Bowel perforation is rare but may be a consequence of noncompliance with the
treatment, because the disease would continue to progress. Diarrhea, vomiting, and intestinal
obstructions are common symptoms of Crohn and may occur even if the client is compliant with
medical care.
B) Bowel perforation is rare but may be a consequence of noncompliance with the treatment,
because the disease would continue to progress. Diarrhea, vomiting, and intestinal obstructions
are common symptoms of Crohn and may occur even if the client is compliant with medical
care.
C) Bowel perforation is rare but may be a consequence of noncompliance with the treatment,
care.
D) Bowel perforation is rare but may be a consequence of noncompliance with the treatment,
care.
Page Ref: 660
Learning Outcome: 2. Identify risk factors and prevention methods associated with IBD.
44
3) An adolescent client with complications related to ulcerative colitis is scheduled for an
ileostomy. The client is concerned about the social effects of this surgery and asks the nurse what
to expect related to bowel function and care after surgery. Which responses from the nurse to the
client are appropriate?
A) "The stoma will require that you wear a collection device all the time."
B) "The drainage tends to be liquid but certain foods can cause it to be paste-like."
C) "The drainage will gradually become semi-solid and formed."
D) "After the stoma heals, you can irrigate your bowel so you won't have to wear a pouch."
E) "You will be able to have some control over your bowel movements."
Answer: A, B
Explanation: A) A client with an ileostomy has no control over bowel movements and must
always wear a collection device. The drainage tends to be liquid but becomes paste-like with the
intake of certain foods.
B) A client with an ileostomy has no control over bowel movements and must always wear a
collection device. The drainage tends to be liquid but becomes paste-like with the intake of
certain foods.
C) A client with an ileostomy has no control over bowel movements and must always wear a
certain foods.
D) A client with an ileostomy has no control over bowel movements and must always wear a
certain foods.
E) A client with an ileostomy has no control over bowel movements and must always wear a
certain foods.
Page Ref: 662-663
Client Need Sub:
across the life span for individuals with IBD.

care:
45
46
4) The nurse provides teaching on the diagnosis Risk for Deficient Fluid Volume to a client with
ulcerative colitis. Which client statement indicates understanding of this information?
A) "I will drink 1 liter of fluid each day."
B) "I will continue to use a moisturizer on my skin."
C) "I should report dry patches of skin immediately to my doctor."
D) "If I have two liquid stools in any day, I will report this to my health care provider."
Answer: A
Explanation: A) The client with irritable bowel syndrome is taught to maintain a higher-than-
normal fluid intake to maintain hydration. The client's dry patches could be due to fluid deficit
but would not require immediate notification. Two liquid stools a day is not excessive, but the
client needs to take in enough fluid to account for the stools as well as the normal fluid needs of
the body. Moisturizing the skin is a positive action of the client but does not indicate appropriate
understanding of the teaching that is appropriate for this diagnosis.
B) The client with irritable bowel syndrome is taught to maintain a higher-than-normal fluid
intake to maintain hydration. The client's dry patches could be due to fluid deficit but would not
require immediate notification. Two liquid stools a day is not excessive, but the client needs to
take in enough fluid to account for the stools as well as the normal fluid needs of the body.
Moisturizing the skin is a positive action of the client but does not indicate appropriate
C) The client with irritable bowel syndrome is taught to maintain a higher-than-normal fluid
D) The client with irritable bowel syndrome is taught to maintain a higher-than-normal fluid
Page Ref: 665-666
Learning Outcome: 7. Evaluate expected outcomes on client with IBD.

care:
47
48
5) The nurse is teaching the family of a school-age client diagnosed with inflammatory bowel
disease on the administration of prednisone at home. At which time should the nurse instruct the
parents to provide the medication to the client?
A) 1 hour before meals
B) At bedtime
C) With meals
D) Between meals
Answer: C
Explanation: A) Prednisone, a corticosteroid, can cause gastric irritation. It should be
administered with meals to reduce the gastric irritation. It should not be given on an empty
stomach.
B) Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals
to reduce the gastric irritation. It should not be given on an empty stomach.
C) Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals
D) Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals
Page Ref: 666
Learning Outcome: 6. Plan evidence-based care for an individual with IBD and his or her family
in collaboration with other members of the healthcare team.
49
6) A home health nurse is evaluating a client who had a colostomy placed 6 weeks ago for the
treatment of ulcerative colitis. Which assessment will cause the nurse to conclude that teaching
goals for this client have been met?
A) A colostomy pouch that is clean and dry
B) Vital signs that reveal a normal temperature
C) A stoma that is pink and intact
D) The client experiences pain with certain types of food.
Answer: C
Explanation: A) Stoma care is taught to the client after surgery, and the goal is for the stoma to
be pink with intact skin. It is not as critical that the ostomy pouch be clean and dry, particularly if
the client has had a stool. A normal temperature would not be a particular goal for a client 6
weeks postoperatively. Patients with ulcerative colitis are going to have pain when they eat foods
that irritate the bowel, but this is not a goal.
B) Stoma care is taught to the client after surgery, and the goal is for the stoma to be pink with
intact skin. It is not as critical that the ostomy pouch be clean and dry, particularly if the client
has had a stool. A normal temperature would not be a particular goal for a client 6 weeks
postoperatively. Patients with ulcerative colitis are going to have pain when they eat foods that
irritate the bowel, but this is not a goal.
C) Stoma care is taught to the client after surgery, and the goal is for the stoma to be pink with
D) Stoma care is taught to the client after surgery, and the goal is for the stoma to be pink with
Page Ref: 667
Learning Outcome: 7. Evaluate expected outcomes for an individual with IBD.

care:
50
51
7) A client is being scheduled for diagnostic tests to determine the presence of ulcerative colitis.
For which diagnostic tests should the nurse plan to provide teaching?
A) Barium enema
B) Intravenous pyelogram
C) Colonoscopy
D) Upper endoscopy
E) Barium swallow
Answer: A, C, E
Explanation: A) Tests to diagnose irritable bowel syndrome include upper and lower barium
studies and a colonoscopy. An intravenous pyelogram is used to diagnose kidney disorders. An
upper endoscopy is used to diagnose disorders of the esophagus and stomach.
B) Tests to diagnose irritable bowel syndrome include upper and lower barium studies and a
colonoscopy. An intravenous pyelogram is used to diagnose kidney disorders. An upper
endoscopy is used to diagnose disorders of the esophagus and stomach.
C) Tests to diagnose irritable bowel syndrome include upper and lower barium studies and a
D) Tests to diagnose irritable bowel syndrome include upper and lower barium studies and a
E) Tests to diagnose irritable bowel syndrome include upper and lower barium studies and a
Page Ref: 662
care of an individual with IBD.
52
8) A nurse is receiving a client from the emergency department diagnosed with an acute
exacerbation of ulcerative colitis (UC). The nurse anticipates the client may present with which
clinical characteristics?
A) 5-30 diarrhea stools per day with blood and mucus
B) Steady right lower quadrant or periumbilical pain
C) Cramping in left lower quadrant; relieved by defecation
D) Tenderness and mass noted in right lower quadrant
E) Fever, malaise, fatigue
Answer: A, C, E
Explanation: A) With both ulcerative colitis (UC) and Crohn disease, the client experiences
periods of symptom-free remissions with sporadic periods of active disease (flares). However,
each condition has differences in clinical characteristics. With UC, the client may have 5-30
diarrhea stools per day with blood and mucus. Pain associated with UC presents with cramping
in the left lower quadrant which is relieved by defecation. All other clinical manifestations are
unique to Crohn disease.
B) With both ulcerative colitis (UC) and Crohn disease, the client experiences periods of
symptom-free remissions with sporadic periods of active disease (flares). However, each
condition has differences in clinical characteristics. With UC, the client may have 5-30 diarrhea
stools per day with blood and mucus. Pain associated with UC presents with cramping in the left
lower quadrant which is relieved by defecation. All other clinical manifestations are unique to
Crohn disease.
C) With both ulcerative colitis (UC) and Crohn disease, the client experiences periods of
Crohn disease.
D) With both ulcerative colitis (UC) and Crohn disease, the client experiences periods of
Crohn disease.
E) With both ulcerative colitis (UC) and Crohn disease, the client experiences periods of
Crohn disease.
Page Ref: 660
direct and indirect causes of inflammatory bowel disease (IBD).
53
9) A nurse caring for a pediatric client with inflammatory bowel disease (IBD) understands that
there are variances in the presentation of IBD between children and adults. Which variances does
the nurse anticipate for this pediatric client?
A) Children suffer from Crohn disease more frequently than ulcerative colitis
B) Pediatric clients often present with fistulizing or stricturing disease.
C) Pediatric clients usually have colonic involvement.
D) Pediatric clients more often present with left-sided colitis.
E) IBD is more common in females than males in the pediatric population
Answer: A, C
Explanation: A) The pediatric etiology of IBD differs from that of adult-onset IBD. For
example, IBD is more common in males than females in the pediatric population, whereas equal
numbers of adult males and females have IBD. In addition, children suffer from Crohn disease
more frequently than ulcerative colitis; the opposite is true of adults. Adults with Crohn disease
usually present with terminal ileal disease without colonic involvement; the majority of pediatric
clients have ileocolonic or colonic disease. Children with Crohn disease usually present with
inflammatory disease; adults often present with fistulizing or stricturing disease. Similarly,
children with ulcerative colitis usually present with pancolitis, whereas adults more often present
with left-sided colitis.
B) The pediatric etiology of IBD differs from that of adult-onset IBD. For example, IBD is more
common in males than females in the pediatric population, whereas equal numbers of adult
males and females have IBD. In addition, children suffer from Crohn disease more frequently
than ulcerative colitis; the opposite is true of adults. Adults with Crohn disease usually present
with terminal ileal disease without colonic involvement; the majority of pediatric clients have
ileocolonic or colonic disease. Children with Crohn disease usually present with inflammatory
disease; adults often present with fistulizing or stricturing disease. Similarly, children with
ulcerative colitis usually present with pancolitis, whereas adults more often present with left-
sided colitis.
C) The pediatric etiology of IBD differs from that of adult-onset IBD. For example, IBD is more
54
sided colitis.
D) The pediatric etiology of IBD differs from that of adult-onset IBD. For example, IBD is more
sided colitis.
E) The pediatric etiology of IBD differs from that of adult-onset IBD. For example, IBD is more
sided colitis.
Page Ref: 661
across the life span for individuals with IBD.

care:
55
Exemplar 10.4 Nephritis
1) The nurse is caring for a client newly admitted to the medical-surgical unit with
glomerulonephritis. Which classic manifestations of this disorder should the nurse expect to
assess in this client?
A) Edema
B) Weight loss
C) Hematuria
D) Acute flank pain
E) Proteinuria
Answer: A, C, E
Explanation: A) Hematuria, proteinuria, and edema are the classic signs of glomerular disease
because this disorder affects the structure and function of the glomerulus, disrupting glomerular
filtration. This increased permeability in the glomeruli leads to plasma proteins being lost in the
urine as well as red blood cells. Edema occurs because of the loss of plasma proteins, namely
albumin. Acute flank pain is often more characteristic of renal calculi. Weight loss is a
nonspecific symptom that can occur with many disorders, but not typically with
glomerulonephritis.
B) Hematuria, proteinuria, and edema are the classic signs of glomerular disease because this
disorder affects the structure and function of the glomerulus, disrupting glomerular filtration.
This increased permeability in the glomeruli leads to plasma proteins being lost in the urine as
well as red blood cells. Edema occurs because of the loss of plasma proteins, namely albumin.
Acute flank pain is often more characteristic of renal calculi. Weight loss is a nonspecific
symptom that can occur with many disorders, but not typically with glomerulonephritis.
C) Hematuria, proteinuria, and edema are the classic signs of glomerular disease because this
D) Hematuria, proteinuria, and edema are the classic signs of glomerular disease because this
56
E) Hematuria, proteinuria, and edema are the classic signs of glomerular disease because this
Page Ref: 671
direct and indirect causes of nephritis.
57
2) The nurse conducts an evaluation after completing a training session for community members
on ways to prevent nephritis. When evaluating the success of this session, what responses should
the members provide as evidence that learning has been successful?
A) Practicing good hygiene
B) Not smoking
C) Maintaining a healthy body weight
D) Limiting alcohol intake
E) Controlling high blood pressure
Answer: A, B, C, E
Explanation: A) The exact cause of nephritis is unknown, but preventing viral infections through
practicing good hygiene habits, not smoking, maintaining a healthy body weight, and controlling
high blood pressure reduces the risk of developing this disease. Limiting alcohol intake will not
affect the development of nephritis.
B) The exact cause of nephritis is unknown, but preventing viral infections through practicing
good hygiene habits, not smoking, maintaining a healthy body weight, and controlling high
blood pressure reduces the risk of developing this disease. Limiting alcohol intake will not affect
the development of nephritis.
C) The exact cause of nephritis is unknown, but preventing viral infections through practicing
D) The exact cause of nephritis is unknown, but preventing viral infections through practicing
E) The exact cause of nephritis is unknown, but preventing viral infections through practicing
Page Ref: 671
Cognitive Level: Remembering
Client Need Sub:
Learning Outcome: 2. Identify risk factors and prevention methods associated with nephritis.
58
3) The nurse is caring for an African-American client with nephritis. For which long-term
complication should the nurse include interventions to prevent when planning this client's care?
A) Congestive heart failure
B) Diabetes mellitus
C) End-stage renal disease
D) Hypertension
Answer: C
Explanation: A) African-Americans are more likely than Caucasians to progress to end-stage
renal disease after nephritis. The nurse should plan interventions to prevent the development of
this long-term complication. African-Americans are not more likely to develop congestive heart
failure, diabetes mellitus, or hypertension after nephritis.
B) African-Americans are more likely than Caucasians to progress to end-stage renal disease
after nephritis. The nurse should plan interventions to prevent the development of this long-term
complication. African-Americans are not more likely to develop congestive heart failure,
diabetes mellitus, or hypertension after nephritis.
C) African-Americans are more likely than Caucasians to progress to end-stage renal disease
D) African-Americans are more likely than Caucasians to progress to end-stage renal disease
Page Ref: 671
across the life span for individuals with nephritis.

care:
59
60
4) The nurse has identified the diagnosis Excess Fluid Volume as appropriate for a client with
acute glomerulonephritis. What should the nurse assess to learn the most accurate indication of
this client's fluid balance?
A) Vital signs
B) Intake and output records
C) Daily weight
D) Serum sodium levels
Answer: C
Explanation: A) Daily weight provides the most accurate indication of fluid balance because of
the pathophysiology of acute glomerulonephritis. Albumin is lost, causing decreased osmotic
pressure and fluid shifting into the interstitial spaces. Accurate weights will provide data to
indicate that treatments are effective in pulling fluids from interstitial spaces into the vascular
system and then out via kidneys. Intake and output records, serum sodium levels, and vital signs
will all provide data indicating fluid balance; however, they are not as accurate as daily weight
for determining fluid balance.
B) Daily weight provides the most accurate indication of fluid balance because of the
pathophysiology of acute glomerulonephritis. Albumin is lost, causing decreased osmotic
C) Daily weight provides the most accurate indication of fluid balance because of the
D) Daily weight provides the most accurate indication of fluid balance because of the
Page Ref: 673
nephritis.

care:
61
62
5) A client being discharged after treatment for nephritis is concerned about having adequate
stamina to care for the children after discharge. Which statement made by the nurse would be
most appropriate to address the client's concern?
A) "Tell your spouse he has to help you."
B) "You will be able to keep up with your family's needs once you return home."
C) It sounds like you need some help, so I'll contact Social Services for support."
D) "Maybe your children should go and stay with a relative or neighbor for a few weeks."
Answer: C
Explanation: A) The nurse should not assume that the client has a spouse. The client will be
easily fatigued and will need assistance after treatment for nephritis. The nurse should contact
Social Services to obtain support for the client. The client might not have family nearby or
neighbors who are available to care for her children for a few weeks.
B) The nurse should not assume that the client has a spouse. The client will be easily fatigued
and will need assistance after treatment for nephritis. The nurse should contact Social Services to
obtain support for the client. The client might not have family nearby or neighbors who are
available to care for her children for a few weeks.
C) The nurse should not assume that the client has a spouse. The client will be easily fatigued
D) The nurse should not assume that the client has a spouse. The client will be easily fatigued
Page Ref: 674
Client Need Sub:
Learning Outcome: 6. Plan evidence-based care for an individual with nephritis and his or her
family in collaboration with other members of the healthcare team.
63
6) A client is experiencing weight gain and foamy dark urine 4 weeks after being treated with
antibiotics for a sore throat. Which client statement, made during the health history assessment,
should the nurse provide further instruction?
A) "I have been trying to get plenty of rest since I have been sick."
B) "I have changed to a more nutritious diet."
C) "I felt better after 1 week of the antibiotics, so I stopped taking them."
D) "I have gained weight in the last 2 weeks."
Answer: C
Explanation: A) The client probably had strep throat and did not take the full course of
antibiotics, which accounts for the current symptoms that indicate glomerulonephritis. The nurse
teaches this client about the importance of taking medications as prescribed to prevent further
complications of a disease. Resting when ill is appropriate, as is changing to a more nutritious
diet. Gaining weight would support the nurse's suspicion that the client has glomerulonephritis.
B) The client probably had strep throat and did not take the full course of antibiotics, which
accounts for the current symptoms that indicate glomerulonephritis. The nurse teaches this client
about the importance of taking medications as prescribed to prevent further complications of a
disease. Resting when ill is appropriate, as is changing to a more nutritious diet. Gaining weight
would support the nurse's suspicion that the client has glomerulonephritis.
C) The client probably had strep throat and did not take the full course of antibiotics, which
D) The client probably had strep throat and did not take the full course of antibiotics, which
Page Ref: 675
Learning Outcome: 7. Evaluate expected outcomes for an individual with nephritis.

care:
64
65
7) A client being treated for nephritic syndrome is a vegetarian and has a poor oral intake. Which
action should the nurse take to meet this client's nutritional needs?
A) Request that the healthcare provider prescribe an appetite stimulant.
B) Request a dietician to discuss the client's dietary preferences.
C) Encourage the client to eat the food provided on the meal trays.
D) Explain that the client will be returning home soon and can resume a preferred diet.
Answer: B
Explanation: A) The client is being treated for nephritic syndrome, which could impact the
amount of protein permitted to be eaten each day. The client should discuss dietary preferences
with a dietician so that the client's nutritional needs will be met. An appetite stimulant is not
going to improve the client's appetite if foods are provided that the client does not eat. The nurse
should not encourage the client to eat foods that do not support the client's vegetarian diet. The
nurse needs to help the client now and not have the client wait to go to home before having foods
that the client wants to eat.
B) The client is being treated for nephritic syndrome, which could impact the amount of protein
permitted to be eaten each day. The client should discuss dietary preferences with a dietician so
that the client's nutritional needs will be met. An appetite stimulant is not going to improve the
client's appetite if foods are provided that the client does not eat. The nurse should not encourage
the client to eat foods that do not support the client's vegetarian diet. The nurse needs to help the
client now and not have the client wait to go to home before having foods that the client wants to
eat.
C) The client is being treated for nephritic syndrome, which could impact the amount of protein
eat.
D) The client is being treated for nephritic syndrome, which could impact the amount of protein
eat.
Page Ref: 674
care of an individual with nephritis.
66
67
8) A child who is hospitalized with acute glomerulonephritis experiences blurred vision and
headache while in the playroom. Which action by the nurse is the most appropriate?
A) Reassure the child and encourage bed rest until the headache improves.
B) Obtain the child's blood pressure and notify the physician.
C) Check the urine to see if hematuria has increased.
D) Obtain serum electrolytes and send a urinalysis to the lab.
Answer: B
Explanation: A) Blurred vision and headache may be signs of encephalopathy, a complication of
acute glomerulonephritis. The nurse should obtain a blood pressure reading and notify the
physician. The physician may decide to order an antihypertensive to bring down the blood
pressure. This is a serious complication, and delay in treatment could mean lethargy and
seizures. Therefore, the other options (checking urine for hematuria, encouraging bed rest, and
obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.
B) Blurred vision and headache may be signs of encephalopathy, a complication of acute
glomerulonephritis. The nurse student should obtain a blood pressure reading and notify the
physician. The physician may decide to order an antihypertensive to bring down the blood
pressure. This is a serious complication, and delay in treatment could mean lethargy and
seizures. Therefore, the other options (checking urine for hematuria, encouraging bed rest, and
obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.
C) Blurred vision and headache may be signs of encephalopathy, a complication of acute
glomerulonephritis. The nurse should obtain a blood pressure reading and notify the physician.
The physician may decide to order an antihypertensive to bring down the blood pressure. This is
a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the
other options (checking urine for hematuria, encouraging bed rest, and obtaining serum
electrolytes) do not directly address the potential problem of encephalopathy.
D) Blurred vision and headache may be signs of encephalopathy, a complication of acute
glomerulonephritis. The nurse should obtain a blood pressure reading and notify the physician.
The physician may decide to order an antihypertensive to bring down the blood pressure. This is
a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the
other options (checking urine for hematuria, encouraging bed rest, and obtaining serum
electrolytes) do not directly address the potential problem of encephalopathy.
Page Ref: 672
Learning Outcome: 6. Plan evidence-based care for an individual with nephritis and his or her
family in collaboration with other members of the healthcare team.
68
69
Exemplar 10.5 Peptic Ulcer Disease
1) A client is being treated with blood transfusions for a large peptic ulcer in the duodenum.
Which information in the client's history should the nurse suspect as causing this health
problem?
A) Allergies to penicillin and morphine sulfate
B) History of chronic atrial fibrillation
C) Daily medications include naproxen sodium and warfarin (Coumadin).
D) Six weeks postoperative cataract extraction with lens implant
Answer: C
Explanation: A) Patients who are taking high doses of nonsteroidal anti-inflammatory agents
(NSAIDs) such as naproxen sodium and anticoagulants such as warfarin are predisposed to
developing large ulcers that do not cause pain. The first symptom the client often experiences is
a significant bleeding episode. Concurrent use of NSAIDs and anticoagulants should be avoided.
The allergy to penicillin and morphine sulfate, history of atrial fibrillation, and recent eye
surgery are not relevant to the client's bleeding incident.
B) Patients who are taking high doses of nonsteroidal anti-inflammatory agents (NSAIDs) such
as naproxen sodium and anticoagulants such as warfarin are predisposed to developing large
ulcers that do not cause pain. The first symptom the client often experiences is a significant
bleeding episode. Concurrent use of NSAIDs and anticoagulants should be avoided. The allergy
to penicillin and morphine sulfate, history of atrial fibrillation, and recent eye surgery are not
relevant to the client's bleeding incident.
C) Patients who are taking high doses of nonsteroidal anti-inflammatory agents (NSAIDs) such
D) Patients who are taking high doses of nonsteroidal anti-inflammatory agents (NSAIDs) such
Page Ref: 677
direct and indirect causes of peptic ulcer disease.
70
71
2) The nurse is planning a teaching session for older community members about the risks for
peptic ulcer disease (PUD) found with this age group. What should the nurse include when
teaching this community group?
A) PUD in an older client causes less bleeding than in a younger client.
B) The elderly client experiences more severe abdominal pain than a younger client with PUD.
C) Older clients should undergo colonoscopy when diagnosed with PUD.
D) Peptic ulcer disease (PUD) is likely to be exacerbated by the bacterium H. pylori.
Answer: D
Explanation: A) H. pylori infection is a major factor in the development of ulcers, and
prevalence increases with the age of the client. Seventy to ninety percent of persons with gastric
ulcers and 90% to 100% of clients with duodenal ulcers are found to have this infection. Older
clients experience more bleeding and often have less pain with the ulcer. Bleeding may be the
initial symptom experienced. Patients with peptic ulcers should have upper GI endoscopy
performed to diagnose the problem with visualization and biopsy, not colonoscopy.
B) H. pylori infection is a major factor in the development of ulcers, and prevalence increases
with the age of the client. Seventy to ninety percent of persons with gastric ulcers and 90% to
100% of clients with duodenal ulcers are found to have this infection. Older clients experience
more bleeding and often have less pain with the ulcer. Bleeding may be the initial symptom
experienced. Patients with peptic ulcers should have upper GI endoscopy performed to diagnose
the problem with visualization and biopsy, not colonoscopy.
C) H. pylori infection is a major factor in the development of ulcers, and prevalence increases
D) H. pylori infection is a major factor in the development of ulcers, and prevalence increases
Page Ref: 677-678
Client Need Sub:
Learning Outcome: 2. Identify risk factors and prevention methods associated with peptic ulcer
disease.
72
73
3) The healthcare provider prescribes misoprostol (Cytotec) for a female client for the treatment
of peptic ulcer disease. What should the nurse ask the client prior to administration of this
medication?
A) "Is there any chance that you are pregnant?"
B) "Are you currently sexually active?"
C) "Are your menstrual cycles irregular?"
D) "Do you plan on becoming pregnant in the next few months?"
Answer: A
Explanation: A) Misoprostol (Cytotec) is contraindicated during pregnancy; it is sometimes used
to terminate pregnancies. There is no contraindication for misoprostol (Cytotec) in a client with
irregular menstrual cycles. Misoprostol (Cytotec) is safe as long as the client is not pregnant.
Asking if client is sexually active could be appropriate, but the nurse would also ask if the client
is using birth control.
B) Misoprostol (Cytotec) is contraindicated during pregnancy; it is sometimes used to terminate
pregnancies. There is no contraindication for misoprostol (Cytotec) in a client with irregular
menstrual cycles. Misoprostol (Cytotec) is safe as long as the client is not pregnant. Asking if
client is sexually active could be appropriate, but the nurse would also ask if the client is using
birth control.
C) Misoprostol (Cytotec) is contraindicated during pregnancy; it is sometimes used to terminate
birth control.
D) Misoprostol (Cytotec) is contraindicated during pregnancy; it is sometimes used to terminate
birth control.
Page Ref: 680
across the life span for individuals with peptic ulcer disease.

care:
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4) The nurse is caring for a client who receives H2-receptor antagonists for the treatment of
peptic ulcer disease. Based on the nursing diagnosis Risk for Bleeding, which assessment finding
should the nurse report immediately to the healthcare provider?
A) The client who reports pain after 24 hours of treatment
B) The client who reports episodes of melena
C) The client who reports he is constipated
D) The client who reports he took TUMS® antacids with his H2-receptor antagonist
Answer: B
Explanation: A) Melena could indicate GI bleeding and should be reported to the physician
immediately. The client may still experience pain for several days with this type of medication.
Taking TUMS® antacids with an H2-receptor antagonist will cause deceased absorption of the
H2-receptor antagonist, but this does not need to be reported to the healthcare provider; the nurse
should educate the client. Constipation is a common side effect that does not need to be
immediately reported to the healthcare provider.
B) Melena could indicate GI bleeding and should be reported to the healthcare provider
H2-receptor antagonist, but this does not need to be reported to the physician; the nurse should
educate the client. Constipation is a common side effect that does not need to be immediately
reported to the healthcare provider.
C) Melena could indicate GI bleeding and should be reported to the healthcare provider
D) Melena could indicate GI bleeding and should be reported to the healthcare provider
Page Ref: 678
peptic ulcer disease.

care:
76
77
5) The nurse is teaching a client with a peptic ulcer on appropriate lifestyle alterations. The
family voices questions as to why some of the recommendations have been made. Which
explanation should be offered by the nurse?
A) "Alcohol acts to suppress gastric immunity and should be avoided."
B) "Caffeine intake is often associated with an increase in abdominal pain."
C) "Cigarette smoking doubles the risk of developing peptic ulcer disease and should be
avoided."
D) "Alcohol stimulates gastric acid secretion, which can cause further irritation."
Answer: C
Explanation: A) Alcohol stimulates gastric acid secretion. This excess acid will promote gastric
irritation. Cigarette smoking is a significant risk factor, doubling the risk of PUD. Cigarette
smoking inhibits the secretion of bicarbonate by the pancreas and may cause more rapid transit
of gastric acid into the duodenum. Caffeine is not usually associated with abdominal pain, but it
does increase the risk of peptic ulcer disease.
B) Alcohol stimulates gastric acid secretion. This excess acid will promote gastric irritation.
Cigarette smoking is a significant risk factor, doubling the risk of PUD. Cigarette smoking
inhibits the secretion of bicarbonate by the pancreas and may cause more rapid transit of gastric
acid into the duodenum. Caffeine is not usually associated with abdominal pain, but it does
increase the risk of peptic ulcer disease.
C) Alcohol stimulates gastric acid secretion. This excess acid will promote gastric irritation.
D) Alcohol stimulates gastric acid secretion. This excess acid will promote gastric irritation.
Page Ref: 682
Learning Outcome: 6. Plan evidence-based care for an individual with peptic ulcer disease and
his or her family in collaboration with other members of the healthcare team.
78
6) The nurse provides discharge teaching for a client with peptic ulcer disease (PUD). Which
client statement indicates that teaching has been effective?
A) "I will drink more milk and limit spicy foods."
B) "I will take ibuprofen (Motrin) for my headaches."
C) "I will limit my intake of coffee."
D) "I will join a gym and increase my exercise."
Answer: C
Explanation: A) Specific foods to eat or avoid are not currently encouraged for the treatment of
peptic ulcer disease. Caffeine is a risk factor for PUD, so limiting caffeinated products such as
coffee will be beneficial in the treatment of it. There is no correlation between exercise and the
management of PUD. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a primary cause of
PUD.
B) Specific foods to eat or avoid are not currently encouraged for the treatment of peptic ulcer
disease. Caffeine is a risk factor for PUD, so limiting caffeinated products such as coffee will be
beneficial in the treatment of it. There is no correlation between exercise and the management of
PUD. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a primary cause of PUD.
C) Specific foods to eat or avoid are not currently encouraged for the treatment of peptic ulcer
D) Specific foods to eat or avoid are not currently encouraged for the treatment of peptic ulcer
Page Ref: 678
Learning Outcome: 7. Evaluate expected outcomes for an individual with peptic ulcer disease.

care:
79
80
7) A client with H. pylori asks the nurse why bismuth (Pepto-Bismol) has been prescribed along
with oral antibiotics for treatment. What should the nurse explain about the use of bismuth
(Pepto-Bismol) for treatment of this health problem?
A) "It helps prevent the side effects of antibiotics."
B) "It increases stomach acid to help kill bacteria."
C) "It helps relieve ulcer-related constipation."
D) "It is effective with inhibiting bacterial growth."
E) "It keeps bacteria from sticking in your stomach."
Answer: D, E
Explanation: A) Bismuth compounds (Pepto-Bismol) are added to the antibiotic regimen to
inhibit bacterial growth. Bismuth compounds prevent H. pylori from adhering to the gastric
mucosa. Bismuth does not prevent all side effects of antibiotics. Bismuth does not increase
stomach acid. Bismuth is used to relieve diarrhea, not constipation.
B) Bismuth compounds (Pepto-Bismol) are added to the antibiotic regimen to inhibit bacterial
growth. Bismuth compounds prevent H. pylori from adhering to the gastric mucosa. Bismuth
does not prevent all side effects of antibiotics. Bismuth does not increase stomach acid. Bismuth
is used to relieve diarrhea, not constipation.
C) Bismuth compounds (Pepto-Bismol) are added to the antibiotic regimen to inhibit bacterial
D) Bismuth compounds (Pepto-Bismol) are added to the antibiotic regimen to inhibit bacterial
E) Bismuth compounds (Pepto-Bismol) are added to the antibiotic regimen to inhibit bacterial
Page Ref: 680
care of an individual with peptic ulcer disease.
81
8) The nurse is planning a teaching session regarding peptic ulcers for the residents of an
assisted-living complex. Which concepts about peptic ulcer disease should the nurse include in
the presentation to the residents?
A) A colonoscopy is the most common test used to diagnose the presence of a gastric ulcer.
B) Gastric ulcers are more common than duodenal ulcers.
C) Many peptic ulcers are infected with H. pylori and are treated with antibiotics.
D) The first sign of a peptic ulcer may be serious gastrointestinal bleeding.
E) The individual with a peptic ulcer will most likely experience pain after eating.
Answer: C, D, E
Explanation: A) The client with a peptic ulcer may be largely asymptomatic until there is an
episode of gastrointestinal bleeding. Duodenal ulcers are more common than gastric ulcers. The
individual who has a peptic ulcer will most likely have abdominal pain after food intake. Tests
used to diagnose a gastric ulcer include an endoscopy and H. pylori testing. Peptic ulcers that are
infected with H. pylori will often be treated with antibiotics.
B) The client with a peptic ulcer may be largely asymptomatic until there is an episode of
gastrointestinal bleeding. Duodenal ulcers are more common than gastric ulcers. The individual
who has a peptic ulcer will most likely have abdominal pain after food intake. Tests used to
diagnose a gastric ulcer include an endoscopy and H. pylori testing. Peptic ulcers that are
C) The client with a peptic ulcer may be largely asymptomatic until there is an episode of
D) The client with a peptic ulcer may be largely asymptomatic until there is an episode of
E) The client with a peptic ulcer may be largely asymptomatic until there is an episode of
Page Ref: 678
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9) A nurse is educating a client with peptic ulcer disease (PUD) regarding Helicobacter pylori
and its role in PUD. Which statements by the nurse are appropriate to include in the teaching
session?
A) "The bacteria produces enzymes that improves the efficacy of mucous gel in protecting the
gastric mucosa."
B) "Helicobacter pylori infection is found in about 25% of individuals with PUD."
C) "Your inflammatory response to H. pylori contributes to gastric cell damage."
D) "H. pylori infection increases production of gastric acids."
E) "H. pylori infection is spread by droplets in the air."
Answer: C, D
Explanation: A) Helicobacter pylori infection, found in about 70% of individuals who have
PUD, is unique in colonizing the stomach. It is spread individual to individual (oral-oral or fecal-
oral) and contributes to ulcer formation in several ways. The bacteria produce enzymes that
reduce the efficacy of mucous gel in protecting the gastric mucosa. In addition, the host's
inflammatory response to H. pylori contributes to gastric epithelial cell damage without
producing immunity to the infection. H. pylori infection increases the production of gastric acids.
B) Helicobacter pylori infection, found in about 70% of individuals who have PUD, is unique in
colonizing the stomach. It is spread individual to individual (oral-oral or fecal-oral) and
contributes to ulcer formation in several ways. The bacteria produce enzymes that reduce the
efficacy of mucous gel in protecting the gastric mucosa. In addition, the host's inflammatory
response to H. pylori contributes to gastric epithelial cell damage without producing immunity to
the infection. H. pylori infection increases the production of gastric acids.
C) Helicobacter pylori infection, found in about 70% of individuals who have PUD, is unique in
D) Helicobacter pylori infection, found in about 70% of individuals who have PUD, is unique in
E) Helicobacter pylori infection, found in about 70% of individuals who have PUD, is unique in
Page Ref: 677
Learning Outcome: 2. Identify risk factors and prevention methods associated with peptic ulcer
84
disease.
10)
A nurse caring for a client with a gastric ulcer understands that which are the two most likely
locations of this ulcer to develop?
A) Lesser curvature
B) Greater curvature
C) Distal to the pylorus
D) Proximal to the pylorus
Answer: A, D
Explanation: A) Gastric ulcers often are found on the lesser curvature (not the greater curvature)
and the area immediately proximal (not distal) to the pylorus.
B) Gastric ulcers often are found on the lesser curvature (not the greater curvature) and the area
immediately proximal (not distal) to the pylorus.
C) Gastric ulcers often are found on the lesser curvature (not the greater curvature) and the area
D) Gastric ulcers often are found on the lesser curvature (not the greater curvature) and the area
Page Ref: 677
85
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Another random document with
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y Ariel! What, Ariel, I say! [Enter Ariel.
hanks, gentle Ariel, who hast again
one all my bidding. But for thee my art
ad halted ere its best. Once more receive
y thanks, who am much bound to thee.
Ariel. This time,
ood master Prospero, I serv’d for love
ot duty, and I count your thanks reward
fullest measure. And there be nothing else
ou would of me, then, Prospero, adieu.
rospero. Adieu, gentlest of spirits, Ariel.
[Exit Ariel.
Thunder heard and Prospero vanishes.
Scene VIII.
A room in the palace at Naples.

[Enter Ferdinand and Miranda.
Miranda. O Ferdinand, my love, last night I slept
nd sleeping dream’d, and in my dream I saw
he isle where first you knew me, where we told
ach to the other our fond loves. Methought
was by you companion’d and the hours
d move to music while there pass’d before
ur wond’ring eyes, as for our sole delight,
many folk, strange sorted, who did talk
gether, and at whiles as ’twere a play
nd we beholding it. ’Twas wondrous strange.
Ferdinand. O, my Miranda, sure some power we wot
ot of doth play with us as we at chess
o move the pieces this way first and that,
ecause our will is to’t. Know then that I
d dream the fellow unto yours (if it
very truth were that and nothing more).
ke you, I vis’ted that sweet spot, with you
eside the while, and did behold, as on
stage a company of players strut
heir hour or two, a band of merry folk
ith some that wept and cried out upon fate.
ho knoweth, my Miranda, what doth hap
us when we do sleep? At whiles we note
slumber tokens of a life apart
om this, alike, yet not alike, and who
ay say how far the spirit wanders when
he body sleeps?
Miranda. Would all my dreams were like
this we’ve wak’d from, for ’twas sweet, yet sad,
nd not so sad but that ’twas sweet the more.
would it were to dream again.
Ferdinand. Who knows,
weet Saint Miranda, but it will return?
Soft music again heard.
[Exeunt Ferdinand and Miranda.
II
THE MERCHANT OF VENICE:
ACT SIXTH
THE MERCHANT OF VENICE:
ACT SIXTH
Scene I.
Venice. A street.
Enter Shylock, followed by a rabble of shouting citizens.
First Citizen. Shylock, how speeds thy business at the court?
here is the pound of flesh thou covetest?
Second Citizen. How likest thou the judge from Padua?
Third Citizen. Eh, Jew, an upright judge! thou hast my lord
he duke to thank for thy poor life. Had I
ut been thy judge a halter had been thine,
nd thou had’st swung in’t, yet, beshrew my life,
were pity that good Christian hemp were stretch’d
hang a misbegotten knave like thee.
Fourth Citizen. Shylock, thou infidel, thou should’st have had
he lash on thine old back ten score of times
e they had suffer’d thee from out the court.
Fifth Citizen. A beating shall he have, e’en now, the knave.
[Beats Shylock.
Shylock [striking about him angrily] Aye! kill me, dogs of Christians,
an’ ye will!
eseems the Jew hath no more leave to tread
he stones on Christian streets; he may not breathe
he air a Christian breathes, nor gaze uncheck’d
pon the Christian’s sky; he hath no part
r lot in anything that is, unless
Christian please to nod the head. I hate
e, brood of Satan that ye are! May all
he plagues of Egypt fall upon ye, dogs
f Christians; all the pains—
Fourth Citizen. Nay, gentle Jew,
s said thou must become a Christian, straight;
d Shylock, turn perforce, a “Christian dog!”
ow, greybeard infidel, how lik’st thou this?
Shylock. Eternal torments blister him that asks.
[Exit Shylock, raving.
Second Citizen. A sweet-fac’d Christian will our Shylock make.
would that I might be his cònfessor,
lay such swingeing penance on the knave
s scarce would leave him space to sup his broth
mid the pauses of his punishment.
[Exeunt citizens, with shouts.
Scene II.
Venice. A Room, in Shylock’s House.

[Enter Shylock and Tubal.
Tubal. How now, Shylock! What bitter woe looks from thy face?
What has chanced to thee in the Christian’s court to make thee thus
distraught?
Shylock. O Tubal, Tubal, there dwells no more pity in the
Christian breast than there abides justice therein. I stood for justice
and mine own, before them all; before that smiling, smooth-faced
judge from Padua, and with those false smiles of his he turned
against me the sharp edge of the law. He forbade the shedding of
one drop of the merchant Antonio’s blood—naming therefor some
ancient law, musty for centuries, and that still had gathered dust till it
would serve to bait the Jew with—and so I lost my revenge upon
Antonio. More than that, good Tubal, I lost everything I had to lose.
Tubal. Lost everything! Now, by our ancient prophets, this is woe
indeed.
Shylock. Aye, good Tubal. The half my goods are now adjudged
Antonio’s; the other half, upon my death, goes to the knave,
Lorenzo; that same he that lately stole my ducats and my daughter.
Tubal. And merry havoc will he and thy daughter Jessica make of
thy treasure, Shylock.
Shylock. But there is greater woe to come, good Tubal. To save
this poor remainder of a life have I this day sworn to turn a Christian.
Tubal. Thou, turn Christian! O monstrous deed! Our synagogue
will be put to everlasting shame for this. Nay, good Shylock, it must
not be. It must not be.
Shylock. Have I not said that I am sworn on pain of life? They
would e’en have had my life almost in the open court had I not so
sworn. But hear me, Tubal; I will not die till that I have bethought me
of some secret, sure revenge upon Antonio, or failing this, upon the
taunting, sneering fool they call Gratiano, whom I do loathe e’en as I
loathe Antonio. Moreover I would gladly do some deadly hurt unto
the accursed Paduan judge, an’ it might be so.
Tubal. Then wilt thou still be Hebrew at the heart, good Shylock?
Shylock. How else while yet I bear remembrance of my wrongs?
Have not many of our chosen people done this selfsame thing for
ducats or for life? Kissed the cross before men’s eyes, but spurned it
behind their backs? As I shall do, erewhile. But, O good Tubal, the
apples of Sodom were as sweet morsels in the mouth unto this that I
must do.
Tubal. Hebrew at heart, albeit Christian of countenance.
y, Shylock, it is well. It is well.
[Exeunt.
Scene III.
Venice. Interior of Saint Mark’s.

Organ music heard. Enter a company of noble Venetians with the
Duke and his train, accompanied by Bassanio, Portia, Antonio,
Gratiano, Nerissa and others. Following these, at a little
distance, appear Lorenzo and Jessica, the latter gorgeously
attired. The company pauses before the font. Shylock enters
from the left, led forward by a priest. His gaberdine has been
exchanged for the Christian habit, and in his hand is placed a
crucifix.
Duke. Old Shylock, art thou well content to do
s thus we have ordain’d, which is, that thou
enounce thine ancient Jewish faith, repent
hy sins, and take the holy, solemn vows
Christian takes when on his brow the drops
aptismal glister, and be nam’d anew
ter the Christian custom of our land?
Shylock. Most noble duke, I am content, and do
ereby renounce my nation and my faith,
nd, which is more, raze out of mind the name
hat I have borne these three-score heavy years,
nce it is thy command.
Duke. Cristofero
halt thou be call’d hereafter. Now, good priest,
hine office do with ceremonies meet,
nd make this greybeard Jew a Christian straight.
Solemn music heard, after which Shylock is baptized by the priest,
Antonio at the command of the Duke standing godfather to the
Jew, who makes the required responses in a low voice. While he
is still kneeling the company converse in an undertone.
Gratiano. I much mislike this new made Christian’s face
or would I trust Cristofero for all
s Christian name and meekly mutter’d vows.
Portia. Nay, Gratiano, question not the heart
or rudely draw aside the veil that speech
angs ever ’fore the spirit. Who may say
hat e’en the best among us keeps a faith
oyal to every smallest clause, or does
ot slip at whiles amid the thousand small
equirements of the law. And yet, we do
plore a gentle sentence on these sins
f ours, a pardon that shall make us whole.
for ourselves, then trebly for the Jew
ew come, bewilder’d, to our Christian creed.
Antonio. There will be space enow to doubt the Jew
rn’d Christian, Gratiano, when he shall
ve cause for doubt. ’Twere scantest charity
l then, to bear with him, as we do bear
urselves unto our fellow Christians all.
bitter lesson hath he lately conn’d,
nd he were mad indeed that should neglect
profit by’t.
Gratiano. Belike, belike ’tis thus,
ut yet I do not like Cristofero’s looks;
not be argu’d out of that, i’ faith,
nd say’t again, I much mislike his favour.
Nerissa. Peace, Gratiano, dost not note the duke
ommands to silence, and would speak once more?
hou wilt be ever talking, as thy wont.
Duke. Cristofero, thou bear’st a Christian name
om this day forth. Then look to’t that thou dost
all things as a Christian, not as Jew.
Shylock. In all things as a Christian. Yes. [Aside] Why that’s
evenge! Revenge!
Duke. So must thou quit thy house
Jewry, dwell mid Christian folk, and go
ith Christian folk to church on holy days,
nd wear henceforth the cross thou did’st disdain.
ost hearken unto us, Cristofero?
Shylock. I hear but to obey, dread duke; and thank
hee for thy clemency to me, once Jew,
ut now, within this very selfsame hour,
gasping new born Christian, all unschool’d
duties other Christians know full well,
et earnest still, to act the Christian’s part,
ith hope to better his ensample set.
Gratiano [aside to Bassanio] For all thy gentle Portia saith but now,
ke not such smooth terms from out those lips.
Bassanio [aside] Peace, Gratiano, let him say his say,
e cannot now do aught to injure thee.
[Exeunt Duke and train with Antonio and
friends. Lorenzo and Jessica come forward.
Jessica. How now, good father Cristofero; what a pair of
Christians are we both. Only there’s this difference betwixt us, good
father. I am a Christian for love of a husband and you have turned a
Christian for love of your ducats.
Shylock. Ungrateful daughter; Why did’st thou go forth from my
house by night and rob thy grey-haired father of his treasure?
Jessica. Why? That’s most easy of answer. Why, because I
desired a Christian husband and there was no coming by my desire
save by secret flight from your most gloomy chambers; and since
neither my Christian husband nor your daughter Jessica could by
any kind of contriving live upon air alone, we had, perforce, to take
with us some of your ducats for the bettering our condition. Speak
thou for me, Lorenzo. Was it not e’en so?
Lorenzo. Old man, I am sorry for that I was forced to take from
you your daughter and your ducats against your good pleasure, but I
must tell you that I loved her as myself [Aside] nay, much more, my
Jessica,—and by reason of this great love of mine, and because of
your exceeding hatred towards all Christians did I take her from your
house. And since, moreover, as the maid very truly says, there’s no
living i’ the world without the means to live, because of this did we
make shift to take with us from your house such means, as well
advised you would not have your daughter lack for food and suitable
apparel, and since we are now Christians all, what matters it?
Shylock [slowly] Ay, what matters it? We are now Christians all,
as thou sayest, and, I remember me that I have heard it said it is a
Christian’s duty to forgive all who have wronged him. Therefore I
forgive you, Jessica—for robbing your old father; and you, Lorenzo, I
forgive—for stealing my daughter. You are each well mated. But I
would be alone a while. Go, good Jessica. Go, son Lorenzo.
[Exeunt Lorenzo and Jessica.
Shylock [alone] A curse pursue the twain where’er they go.
Christian-Jewish curse, since that should be
eightier than either singly. Would that I
ght see them dead before me, while I live,—
uch love I bear my daughter, and my son.
[Gazes about the church.
hese be the images of Christian saints
hom I must bend the knee before when men
ook on. And here the Virgin; here the Christ.
ow must I kneel; a hundred eyes perchance,
eer at me through the gloom. A hundred eyes
ay see me kneel, yet shall they not perceive
he scorner of the Christian hid within
he humble figure of the man who kneels.
ow, by the prophets, whom I reverence,
nd by these Christian saints whom I do scorn,
wear to nourish my revenge till those
eepest hate are dead, or sham’d before
heir fellows. But how this may be, I know
ot yet, for all the way were dark as night
efore me, save that my revenge burns red.
[Choir heard chanting in a distant chapel.
[Rises from his knees.
ood fellow Christians, it may hap the Jew
rn’d Christian, shall yet do a harm to ye.
ehind Cristofero’s mask is still the face
f Shylock; in his breast the heart unchang’d.
[Choir heard chanting Judica me Deus.
ea, my good fellow Christians, I do thank
e for that word, and hug it to my heart.
enceforth it shall be mine, when I do pray,
ot to thy Christ, but unto Israel’s God!
ive sentence with me, O my God; defend
y cause against the hosts that wrought me ill.”
[Choir in the distance, responding Amen.
[Exit Shylock.
NOTE BY WILLIAM J. ROLFE, Litt.D.
It is a tribute of no slight significance to Shakespeare’s skill in the
delineation of character that we instinctively regard the personages
in his mimic world as real men and women, and are not satisfied to
think of them only as they appear on the stage. We like to follow
them after they have left the scene, and to speculate concerning
their subsequent history. The commentators on Much Ado, for
instance, are not willing to dismiss Benedick and Beatrice when the
play closes without discussing the question whether they probably
“lived happily ever after.” Some, like Mrs. Jameson and the poet
Campbell, have their misgivings about the future of the pair, fearing
that “poor Benedick” will not escape the “predestinate scratched
face” which he himself had predicted for the man who should woo
and win that “infernal Até in good apparel,” as he called her; while
others, like Verplanck, Charles Cowden-Clarke, Furnivall, and
Gervinus, believe that their married life will be of “the brightest and
sunniest.”
Some have gone back of the beginning of the plays, like Mrs.
Cowden-Clarke in her Girlhood of Shakespeare’s Heroines, and
Lady Martin (Helena Faucit) in her paper on Ophelia in Some of
Shakespeare’s Female Characters.
Others, like Mr. Adams, have made the experiment of continuing
a play of Shakespeare in dramatic form. Ernest Renan, in France,
and Mr. C. P. Cranch, in this country, have both done this in the case
of The Tempest, mainly with the view of following out the possible
adventures of Caliban after Prospero had left him to his own devices.
These and similar sequels to the plays are nowise meant as
attempts to “improve” Shakespeare (like Nahum Tate’s version of
Lear, that held the stage for a hundred and sixty years) and sundry
other perversions of the plays in the eighteenth century, which have
damned their presumptuous authors to everlasting infamy. They are
what Renan, in his preface, calls his Caliban,—“an idealist’s fancy
sketch, a simple fantasy of the imagination.”
Mr. Adams’s Sixth Act of The Merchant of Venice is an
experiment of the same kind; not, as certain captious critics have
regarded it, a foolhardy attempt to rival Shakespeare. It was
originally written for an evening entertainment of the “Old Cambridge
Shakespeare Association.” No one in that cultivated company
misunderstood the author’s aim, and all heartily enjoyed it. I believe
that it will give no less pleasure to the larger audience to whom it is
now presented in print.
Transcriber’s Note:
Words may have multiple spelling variations or inconsistent
hyphenation in the text. These have been left unchanged. Obsolete
words, alternative spellings, and misspelled words were not
corrected.
Obvious printing errors, such as backwards, reversed, upside
down, or partially printed letters and punctuation, were corrected.
Final stops missing at the end of sentences and abbreviations were
added. Duplicate words at line endings were removed. Right-aligned
stage directions were adjusted so that all are preceded by an open
bracket.
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A room in the palace at Naples.

THE MERCHANT OF VENICE:

Venice. A Room, in Shylock’s House.

Venice. Interior of Saint Mark’s.

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