Nokea
A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet?
- A. High protein and high calorie
- B. High calorie and high carbohydrate
- C. Low-fat 2-g sodium diet
- D. High protein and high fat
Correct Answer: B
Rationale: High carbohydrates provide high-caloric content to prevent tissue catabolism.
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The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?
- A. Monitor fetal heart tones
- B. Administer tocolytics
- C. Place the client in Trendelenburg position
- D. Administer antibiotics
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being. Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.
At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, 'How do I prepare for the test I am scheduled for?' The RN will most likely inform her of the following instructions to help prepare her for the test:
- A. You need to know that an IV is always started before the test.
- B. You will need to drink 6 to 8 glasses of water to fill your bladder.
- C. Do not eat any food or drink any liquids before the test is started.
- D. You will have to remain as still as you possibly can.
Correct Answer: D
Rationale: Any maternal activity can interfere with the results of the nonstress test, as movement may affect fetal heart rate tracings.
A behavior-modification program has been started for an adolescent with oppositional defiant disorder. Which statement describes the use of behavior modification?
- A. Distractors are used to interrupt repetitive or unpleasant thoughts.
- B. Techniques using stressors and exercise are used to increase awareness of body defenses.
- C. A system of tokens and rewards is used as positive reinforcement.
- D. Appropriate behavior is learned through observing the action of models.
Correct Answer: C
Rationale: Behavior modification for oppositional defiant disorder often uses a token economy system, where positive behaviors are reinforced with rewards to encourage compliance.
The client is admitted with a diagnosis of preeclampsia. The nurse should monitor for which complication?
- A. Seizures
- B. Premature rupture of membranes
- C. Fetal macrosomia
- D. Maternal hypoglycemia
Correct Answer: A
Rationale: Preeclampsia can progress to eclampsia characterized by seizures a life-threatening complication. Premature rupture of membranes macrosomia and hypoglycemia are not directly related to preeclampsia.
The client is admitted with a diagnosis of placenta accreta. Which complication is most likely to occur?
- A. Maternal hemorrhage
- B. Fetal distress
- C. Preterm labor
- D. All of the above
Correct Answer: D
Rationale: Placenta accreta where the placenta abnormally adheres to the uterine wall increases the risk of maternal hemorrhage (during delivery) fetal distress (from placental dysfunction) and preterm labor (from interventions). All are potential complications.