Nokea
The nurse is caring for a client with liver cirrhosis. Which of these findings would indicate that the client is experiencing complications of the disease?
- A. Yellowing of the skin and eyes
- B. Presence of spider angiomas on the skin
- C. Ascites and peripheral edema
- D. Clay-colored stools and dark urine
Correct Answer: D
Rationale: Clay-colored stools and dark urine are classic signs of liver dysfunction, indicating bile flow obstruction commonly seen in liver cirrhosis. This finding is a significant complication requiring immediate medical evaluation. Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction but is not specific to complications. Spider angiomas and ascites with peripheral edema are also associated with liver cirrhosis, but they are not indicative of immediate complications as clay-colored stools and dark urine are.
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A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?
- A. Check the protein level in urine
- B. Have the client turn to the left side
- C. Take the temperature
- D. Monitor the urine output
Correct Answer: B
Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.
A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 episodes of incontinent diarrhea
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: A malnourished client on bed rest is at the highest risk for developing decubitus ulcers due to a combination of factors such as poor nutritional status and immobility. Malnourished individuals have compromised skin integrity, making them more susceptible to pressure ulcers. Being on bed rest further exacerbates this risk as constant pressure on bony prominences can lead to tissue damage. Although the other choices may also be at risk for developing decubitus ulcers, the malnourished client on bed rest presents the highest risk due to the combination of malnutrition and immobility.
What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
- A. Presence of blood in stools
- B. Oozing liquid stool
- C. Continuous rumbling flatulence
- D. Absence of bowel movements
Correct Answer: B
Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.
A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching?
- A. Vitamin A
- B. Vitamin B1
- C. Vitamin C
- D. Vitamin B12
Correct Answer: A
Rationale: The correct answer is Vitamin A. Fat-soluble vitamins essential for patients with pancreatitis include A, D, E, and K, aiding in proper nutrient absorption. Vitamin B1 (Choice B), also known as thiamine, is a water-soluble vitamin and not a fat-soluble one. Vitamin C (Choice C) is another water-soluble vitamin and not a fat-soluble one. Vitamin B12 (Choice D) is also a water-soluble vitamin and not one of the fat-soluble vitamins crucial for patients with pancreatitis.
A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?
- A. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles are usually left in for 15 to 30 minutes.
- B. In traditional Chinese medicine, imbalances in the basic energetic flow of life - known as qi or chi - are thought to cause illness.
- C. The flow of life is believed to flow through major pathways in your body rather than nerve clusters.
- D. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations, it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.
Correct Answer: C
Rationale: The belief stated in option C is incorrect about acupuncture. Acupuncture is based on the concept of qi flowing through major pathways in the body, known as meridians, rather than nerve clusters. This traditional Chinese medicine practice aims to balance the flow of qi to promote health and healing. Options A, B, and D are consistent with the principles of acupuncture and are not incorrect beliefs. Option A describes the depth and duration of needle placement, option B explains the role of imbalances in qi flow causing illness, and option D outlines how acupuncture helps rebalance energy flow for the body's natural healing mechanisms.