A client with a history of cirrhosis is admitted with jaundice. The nurse should include which of the following in the plan of care?
- A. Monitor for signs of bleeding.
- B. Encourage a high-fat diet.
- C. Administer vitamin C.
- D. Restrict protein intake.
Correct Answer: A
Rationale: Jaundice in cirrhosis indicates liver dysfunction, increasing bleeding risk due to impaired clotting factor production.
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Which of the following is appropriate when developing a plan of care for promoting the development of a preschooler? Select all that apply.
- A. Providing anticipatory guidance for parents.
- B. Helping the parents understand their child's behavior.
- C. Identifying deviations from normal growth and development patterns.
- D. Determining the child's future development.
- E. Sending the child to a day care center.
Correct Answer: A,B,C
Rationale: Anticipatory guidance, understanding behavior, and identifying deviations support preschooler development. Predicting future development is not feasible, and daycare is not universally required.
The mother of a 3-year-old child tells the nurse her child is 'fussy' and not as 'easy going' as her other children. She is having difficulty feeding the child because he fusses and cries when she serves a meal. The nurse should instruct the mother to:
- A. Allow the child to determine when feeding should occur.
- B. Not to feed the child if he cries.
- C. Provide structured feeding times and routines.
- D. Give the child finger foods and let him eat when he wants.
Correct Answer: C
Rationale: Structured feeding times and routines help establish consistent eating habits, reducing fussiness by providing predictability for the child.
A client who has had a laparoscopic cholecystectomy receives discharge instructions from the nurse. Which statement indicates that the client has understood the instructions?
- A. I need to maintain a low-fat diet for the next 6 months
- B. I can remove the dressing from my incision tomorrow and take a shower
- C. I can anticipate some nausea for several days after surgery
- D. I can return to work in 4 to 6 weeks
Correct Answer: B
Rationale: Removing the dressing and showering the day after a laparoscopic cholecystectomy is standard, as incisions are small. A low-fat diet may be advised but not for a fixed 6 months, nausea is not expected, and return to work is typically sooner.
A client with a diagnosis of gout is prescribed naproxen. The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking naproxen with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
A client is admitted with a diagnosis of acute pancreatitis. The nurse should expect the client to report which of the following symptoms?
- A. Pain radiating to the right shoulder.
- B. Epigastric pain radiating to the back.
- C. Right lower quadrant pain.
- D. Diffuse lower abdominal pain.
Correct Answer: B
Rationale: Acute pancreatitis typically causes epigastric pain that radiates to the back due to pancreatic inflammation.
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