Nokea
The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin K absorption caused by this liver disease?
- A. Dyspnea and fatigue
- B. Ascites and orthopnea
- C. Purpura and petechiae
- D. Gynecomastia and testicular atrophy
Correct Answer: C
Rationale: A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
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The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:
- A. Upper quadrant and radiates to the left scapula and shoulder
- B. Upper quadrant and radiates to the right scapula and shoulder
- C. Lower quadrant and radiates to the umbilicus
- D. Lower quadrant and radiates to the back
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is providing discharge instructions to a client following gastrectomy. Which measure will the nurse instruct the client to follow to assist in preventing dumping syndrome?
- A. Eat high-carbohydrate foods
- B. Limit the fluids taken with meals
- C. Ambulate following a meal
- D. Sit in a high-Fowlers position during meals
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with liver dysfunction is having difficulty with protein metabolism. The nurse anticipates that the results of which of the following serum laboratory studies will be elevated?
- A. Lactic acid
- B. Ammonia
- C. Albumin
- D. Lactase
Correct Answer: B
Rationale: During deamination of proteins, the liver splits the amino group from the carbon-containing compound, which results in the formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result.
The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
- A. The client complains of a sore throat
- B. The client has a temperature of 100*F
- C. The client appears drowsy following the procedure
- D. The client complains of epigastric pain
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:
- A. Decreases food absorption in the stomach
- B. Heals the gastric mucosa
- C. Halts stress reactions
- D. Reduces the stimulus to acid secretions
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.