Nokea
A client with a history of liver cirrhosis is admitted with ascites. The nurse should monitor the client for which of the following complications?
- A. Hypotension.
- B. Respiratory distress.
- C. Hyperkalemia.
- D. Hypoglycemia.
Correct Answer: B
Rationale: Ascites can compress the diaphragm, leading to respiratory distress, a complication the nurse should monitor for in cirrhosis.
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A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
- A. Protein.
- B. Carbohydrate.
- C. Fat.
- D. Water.
Correct Answer: B
Rationale: Carbohydrates are the primary energy source for sustained physical activity, providing glycogen stores for endurance.
Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. 1. The vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5. The exudate phase 6. The convalescence phase
- A. 4,2,1
- B. 4,1,5
- C. 4,5,1
- D. 4,2,5
Correct Answer: B
Rationale: The inflammatory response includes the initial injury (4), followed by the vascular phase (1, vasodilation and increased permeability), and then the exudate phase (5, fluid and cell migration). Prodromal (2), incubation (3), and convalescence (6) are not part of the inflammatory process. Thus, B (4,1,5) is correct.
The nurse is obtaining a health history from a Mexican American adult. The nurse should interpret the findings by understanding that Mexican American culture most highly values:
- A. Children
- B. Materialism
- C. Firstborn sons
- D. The elderly
Correct Answer: A
Rationale: Mexican American culture often places high value on children, emphasizing family and intergenerational bonds. Materialism, firstborn sons, and the elderly are valued but not as universally central.
The nurse is discussing safety and accident prevention with the mother of a 9-month-old. The teaching has been effective when the mother states which of the following?
- A. I make sure that I keep my cleaning supplies locked up.'
- B. Sometimes she plays in the bathroom when I'm cleaning in there.'
- C. Occasionally she gets under the chair and plays with the telephone cord.'
- D. I've found that those child-protective cabinet locks don't work very well.'
Correct Answer: A
Rationale: Keeping cleaning supplies locked up indicates effective teaching on safety, as it prevents the child from accessing hazardous substances.
The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?
- A. Changes in vital signs
- B. Signs of vaginal bruising
- C. Client reporting a tearing sensation
- D. Client reporting intense vaginal pressure
Correct Answer: A
Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Because the client received anesthesia, she would not feel pain or pressure.