Nokea
A client with a history of cirrhosis is admitted with ascites. Which dietary modification should the nurse recommend?
- A. Low-sodium diet
- B. High-protein diet
- C. Low-fat diet
- D. High-carbohydrate diet
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention in ascites, helping to manage symptoms in clients with cirrhosis.
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Which of the following steps is the final step that is used during the physical assessment of the abdomen?
- A. Inspection
- B. Light palpation
- C. Deep palpation
- D. Percussion
Correct Answer: C
Rationale: The standard sequence for abdominal assessment is inspection, auscultation, percussion, and palpation (light then deep). Deep palpation is the final step to assess for organ size or abnormalities.
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:
- A. Kussmaul's respirations
- B. Excessive hunger
- C. Dry, flaky skin
- D. High blood pressure
Correct Answer: A
Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.
The nurse is assessing a client with a suspected spinal cord injury. Which of the following findings is most indicative of this condition?
- A. Loss of sensation below the injury site.
- B. Increased muscle tone in the arms.
- C. Normal bowel and bladder function.
- D. Absence of pain at the injury site.
Correct Answer: A
Rationale: Loss of sensation below the injury site is a hallmark sign of spinal cord injury due to disrupted nerve pathways.
A client is diagnosed with pernicious anemia. The nurse reviews the client's health history for disorders involving which organ responsible for vitamin B12 absorption?
- A. Liver
- B. Ileum
- C. Kidney
- D. Hepatobiliary
Correct Answer: B
Rationale: Pernicious anemia can occur in a client who has a disease involving the ileum, where vitamin B12 is absorbed. The nurse checks the client's history for small bowel disorders to detect this risk factor. The liver and the kidney are not related to impaired B12 absorption. Hepatobiliary refers to the liver and gallbladder.
A client who voluntarily admitted herself to the mental health hospital adamantly demands to be discharged immediately. What is the most appropriate response by the nurse?
- A. We hate to see you go, but that is your right. I'll get the forms for you so you can go.'
- B. I'm sorry, but your lawyer or family must request such forms when you are hospitalized.'
- C. I will get the forms, but your psychiatrist will need to see you before you leave.'
- D. Are you sure we can't convince you to stay here in a few days? You'll return to a full valid and there are several issues we need to address.'
Correct Answer: C
Rationale: For voluntary admissions, clients can request discharge, but a psychiatric evaluation is typically required to ensure safety. This response ensures protocol is followed while addressing the client's request.