Nokea
A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?
- A. Avoid high carbohydrate foods.
- B. Decrease intake of fat-soluble vitamins.
- C. Decrease caloric intake.
- D. Restrict salt and fluid intake.
Correct Answer: D
Rationale: The correct answer is to restrict salt and fluid intake. In clients with cirrhosis presenting with pedal edema and ascites, excessive fluid retention occurs, necessitating the restriction of salt and fluid to alleviate these symptoms. Choice A, avoiding high carbohydrate foods, is not the priority in this situation. Decreasing intake of fat-soluble vitamins (Choice B) is not specifically indicated for managing edema and ascites in cirrhosis. While maintaining an appropriate caloric intake is important, decreasing caloric intake (Choice C) is not the primary focus when addressing fluid retention in cirrhosis.
You may also like to solve these questions
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client?
- A. Impaired communication related to paralysis of skeletal muscles.
- B. High risk for infection related to increased intracranial pressure.
- C. Potential for injury related to impaired lung expansion.
- D. Social isolation related to inability to communicate.
Correct Answer: A
Rationale: The priority nursing diagnosis for a client on a mechanical ventilator receiving vecuronium bromide is 'Impaired communication related to paralysis of skeletal muscles.' Vecuronium is a skeletal muscle relaxant that causes diaphragmatic paralysis, leading to the inability of the client to communicate effectively. This is a crucial nursing concern as it impacts the client's ability to express needs and participate in care. Option B 'High risk for infection related to increased intracranial pressure' is not the priority in this scenario as the client's condition is related to the effects of the medication and mechanical ventilation, not directly to increased intracranial pressure. Option C 'Potential for injury related to impaired lung expansion' is important but not the priority over impaired communication. Option D 'Social isolation related to inability to communicate' is not the priority nursing diagnosis in this situation as it focuses more on psychosocial aspects rather than the immediate physiological concern of communication impairment.
A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?
- A. Notify social services immediately if suspected elderly abuse is present.
- B. Discuss the need for mental health counseling with the daughter.
- C. Explain to the client the importance of taking better care of herself.
- D. Collect further data to determine whether self-neglect is occurring.
Correct Answer: D
Rationale: In this scenario, the client presents with significant weight loss, poor hygiene, and inadequate clothing, which are concerning signs of self-neglect. Before taking action, it is crucial for the nurse to collect more data to determine the root cause of these issues. Jumping to conclusions or immediately involving social services without a thorough assessment could potentially harm the client or strain relationships. Discussing the need for mental health counseling with the daughter or simply advising the client to take better care of herself may not address the underlying problem of self-neglect. Therefore, the most appropriate initial action is for the nurse to collect further data to make an informed decision before taking the next steps.
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?
- A. Explain the effects of follicle-stimulating and luteinizing hormones.
- B. Discuss perimenopause and related comfort measures.
- C. Assess lung fields and check for a cough productive of blood-tinged mucus.
- D. Inquire if a fever above 101°F (38.3°C) has occurred in the last 24 hours.
Correct Answer: B
Rationale: The correct answer is B. The symptoms described by the client, excessive diaphoresis and feeling warm at night, are characteristic of perimenopause. During this period, lower estrogen levels lead to surges in follicle-stimulating hormone (FSH) and luteinizing hormone (LH), resulting in vasomotor instability, night sweats, and hot flashes. Therefore, discussing perimenopause and related comfort measures with the client is essential to provide education and support. Choice A is incorrect because explaining the effects of FSH and LH alone does not directly address the client's current symptoms. Choice C is irrelevant as it focuses on assessing lung fields and cough symptoms, which are not related to the client's menopausal symptoms. Choice D is not the best response as it is more focused on ruling out fever as a cause, which is not typically associated with the symptoms described by the client.
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless, and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:
- A. Notify the surgeon
- B. Continue the assessment
- C. Check the client's blood pressure
- D. Obtain a flashlight, gauze, and a curved hemostat
Correct Answer: A
Rationale: In the scenario described, the client's presentation with bright-red blood vomiting after a tonsillectomy and adenoidectomy is highly concerning for an immediate postoperative hemorrhage, which can be life-threatening. The priority action for the nurse is to notify the surgeon immediately. Prompt communication with the surgeon is vital to ensure swift intervention and appropriate management to address the hemorrhage effectively. Continuing the assessment, checking the client's blood pressure, or obtaining equipment are all secondary actions in this critical situation and would delay the necessary urgent intervention required to manage the hemorrhage effectively.
Which client should the nurse recognize as most likely to experience sleep apnea?
- A. Middle-aged female who takes a diuretic nightly.
- B. Obese older male client with a short, thick neck.
- C. Adolescent female with a history of tonsillectomy.
- D. School-aged male with a history of hyperactivity disorder.
Correct Answer: B
Rationale: The correct answer is B. Sleep apnea is characterized by pauses in breathing during sleep, often due to a collapsed or blocked airway. Obesity and having a short, thick neck are risk factors for sleep apnea because excess fat around the neck can obstruct the airway. Option A (middle-aged female who takes a diuretic nightly) does not present as a common risk factor for sleep apnea. Option C (adolescent female with a history of tonsillectomy) may have had tonsils removed, which could reduce the risk of sleep apnea. Option D (school-aged male with a history of hyperactivity disorder) is not directly associated with an increased risk of sleep apnea.