Nokea
A client has been diagnosed with viral hepatitis. Which of the following goals is most appropriate for the client?
- A. Achieve control of abdominal pains
- B. Increase activity levels gradually
- C. Reduce jaundice
- D. Prevent liver damage
Correct Answer: B
Rationale: Increasing activity levels gradually is an appropriate goal for viral hepatitis, as rest is needed initially but gradual return to activity supports recovery. Pain is less common, and jaundice or liver damage prevention are secondary.
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You are a hospice nurse who, as part of your role, does follow up counseling and care for the significant others of deceased spouses for one year after their loss. Whose theory of grief and loss would you most likely integrate into your practice as you perform this role?
- A. Engel's theory
- B. Kubler Ross' theory
- C. Lewin's theory
- D. Warden's theory
Correct Answer: B
Rationale: Kubler-Ross' theory of the five stages of grief (denial, anger, bargaining, depression, acceptance) is widely used in hospice care to guide counseling for grieving significant others.
The stages of conflict and conflict resolution in the correct sequential order are:
- A. Conceptualization
- B. Frustration
- C. Resolution
- D. Taking action
Correct Answer: B,A,D,C
Rationale: The correct sequence of conflict stages is Frustration (B, emotional response), Conceptualization (A, understanding the conflict), Taking action (D, implementing solutions), and Resolution (C, resolving the conflict).
The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see figure). The nurse should first:
- A. Position the child supine
- B. Call the rapid response team
- C. Offer the child a carbonated drink
- D. Place the child in a croup tent
Correct Answer: B
Rationale: An 18-month-old with a respiratory tract infection may be in respiratory distress, requiring immediate action by calling the rapid response team. Positioning supine or offering a drink could worsen breathing, and a croup tent is specific to croup, not all infections.
The nurse is caring for a client with a history of burns covering 25% of the body. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor for signs of infection.
- B. Administer I.V. fluids as prescribed.
- C. Apply silver sulfadiazine to burns.
- D. Provide a low-protein diet.
- E. Administer analgesics as needed.
Correct Answer: A, B, C, E
Rationale: Monitoring for infection, I.V. fluids, silver sulfadiazine, and analgesics are essential for burn care. A high-protein diet is needed, not low-protein.
Which of the following abnormal serum chemistry results is a client with cirrhosis who has developed ascites likely to have?
- A. Decreased aspartate aminotransferase.
- B. Hypoalbuminemia.
- C. Hyperkalemia.
- D. Decreased alanine aminotransferase.
Correct Answer: B
Rationale: Cirrhosis impairs liver protein synthesis, leading to hypoalbuminemia, which causes ascites due to decreased oncotic pressure.