Nokea
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
- A. Sodium
- B. Potassium
- C. Protein
- D. Fat
Correct Answer: C
Rationale: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.
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A client with a history of osteoarthritis is admitted with complaints of joint stiffness. The nurse should expect the client to have:
- A. Pain with activity
- B. Morning stiffness lasting hours
- C. Symmetrical joint involvement
- D. Systemic symptoms like fever
Correct Answer: A
Rationale: Osteoarthritis causes joint pain worsened by activity due to cartilage degeneration, unlike rheumatoid arthritis, which involves prolonged morning stiffness.
The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?
- A. Report unexplained muscle weakness to the physician
- B. Allow six months for the drug to take effect
- C. Take the medication with fruit juice
- D. Report difficulty sleeping
Correct Answer: A
Rationale: Rosuvastatin a statin can cause myopathy or rhabdomyolysis. Unexplained muscle weakness is a serious side effect requiring immediate reporting to prevent complications. The other options are not specific to rosuvastatin therapy.
The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection by the client indicates to the nurse that further instruction is needed?
- A. Tuna casserole
- B. Ham salad sandwich
- C. Baked potato
- D. Broiled beef roast
Correct Answer: A
Rationale: Isoniazid has MAOI properties, requiring avoidance of tyramine-rich foods like tuna to prevent hypertensive crisis. Tuna casserole (A) indicates a need for further teaching. Ham salad (B) may have tyramine but is less definitive. Baked potato (C) and beef roast (D) are safe.
A client is admitted with symptoms of pseudomembranous colitis. Which finding is associated with Clostridium difficile?
- A. Diarrhea containing blood and mucus
- B. Cough, fever, and shortness of breath
- C. Anorexia, weight loss, and fever
- D. Development of ulcers on the lower extremities
Correct Answer: A
Rationale: Clostridium difficile causes pseudomembranous colitis, characterized by diarrhea with blood and mucus due to toxin-mediated inflammation of the colon.
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
- A. Apply ice to the cast
- B. Elevate the leg
- C. Massage the leg
- D. Notify the physician immediately
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.