Nokea
A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).
- A. Asterixis
- B. Change in orientation
- C. Anorexia
- D. Ascites
- E. Fetor hepaticus
Correct Answer: A,B,E
Rationale: These are signs of hepatic encephalopathy reflecting cerebral effects of ammonia toxicity.
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A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Bradypnea
- C. Severe pain
- D. Nocturia
Correct Answer: C
Rationale: Severe pain (renal colic) is the most common symptom of renal calculi, caused by the stone moving and blocking the ureter.
A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?
- A. Liver enzymes
- B. Serum albumin
- C. Throat culture
- D. Arterial blood gases
Correct Answer: C
Rationale: Throat culture can identify streptococcal infection preceding rheumatic fever/endocarditis.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hours ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Troponin
- B. Aspartate aminotransferase (AST)
- C. Serum amylase
- D. Unconjugated bilirubin
Correct Answer: A
Rationale: Troponin rises within 3-12 hours post-MI and is the most specific marker for myocardial injury.
A client arrives at the emergency room with symptoms of peptic ulcer disease. Which of these symptoms should the nurse identify as the priority?
- A. Hematemesis
- B. Abdominal bloating
- C. Epigastric discomfort
- D. Dyspepsia
Correct Answer: A
Rationale: Hematemesis indicates active bleeding and is the most urgent concern.
A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypophosphatemia
Correct Answer: D
Rationale: Hypophosphatemia is the hallmark of refeeding syndrome due to intracellular shifts of phosphorus during refeeding.