Nokea
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
- A. It must have been eating too many foods with salt in them. Salt pulls water with it.'
- B. The swelling in his ankles must have moved up closer to his heart so the fluid circulates better.'
- C. He must have forgotten to take his daily water pill.'
- D. Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels.'
Correct Answer: D
Rationale: Cirrhosis causes portal hypertension and hypoalbuminemia, leading to ascites (D). Salt intake (A) may worsen but isn't the primary cause. Ankle edema (B) and diuretics (C) are secondary factors.
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One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse encourages the client to:
- A. Apply heat to the extremity
- B. Elevate the legs above the heart
- C. Stop smoking
- D. Begin a jogging program
Correct Answer: C
Rationale: Stopping smoking promotes vasodilation by reducing nicotine-induced vasoconstriction and improving endothelial function, critical in arterial occlusive disease. Applying heat risks burns in ischemic tissue, elevating legs worsens arterial flow, and jogging may be contraindicated due to claudication.
A client with an ileal conduit reports a bulging stoma. The nurse suspects:
- A. Stoma retraction.
- B. Parastomal hernia.
- C. Stoma ischemia.
- D. Infection.
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
Which of the following activities indicates that the client with cancer is adapting well to body image changes?
- A. The client names his brother as the person to call if he is experiencing suicidal ideation.
- B. The client discusses changes in body structure and function.
- C. The client discusses the date of his return to work.
- D. The client serves as a volunteer in a client-to-client visitation program.
Correct Answer: D
Rationale: Volunteering in a client-to-client program indicates positive adaptation to body image changes, as it reflects confidence and engagement with others despite physical changes.
A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:
- A. A mild but constant aching in the chest.
- B. Severe midsternal pain.
- C. Moderate pain that worsens on inspiration.
- D. Muscle spasm pain that accompanies coughing.
Correct Answer: C
Rationale: Pleuritic chest pain is sharp or moderate and worsens with inspiration due to inflamed pleura. Constant aching, midsternal pain, or muscle spasm pain are not characteristic of pleurisy.
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
- A. Place the client in a private room.
- B. Have the client wear a mask.
- C. Have staff wear gowns and gloves.
- D. Restrict visitors.
Correct Answer: A
Rationale: Clients with ALL are immunocompromised due to neutropenia, increasing infection risk. Placing the client in a private room reduces exposure to pathogens. Masks, gowns, and visitor restrictions may be used in severe cases, but a private room is the first step.