Nokea
A client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?
- A. Esophageal varices
- B. Ascites
- C. Peripheral edema
- D. Asterixis (liver flap)
Correct Answer: A
Rationale: Esophageal varices can rupture and cause life-threatening hemorrhage, making them the most serious complication.
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A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?
- A. Turkey sandwich with celery sticks
- B. Sliced ham with green salad
- C. Pork tenderloin with green peas
- D. Grilled chicken breast with white rice
Correct Answer: D
Rationale: The correct answer is D because grilled chicken breast with white rice is a low-fiber, easily digestible option suitable for a client with diverticulitis. High-fiber foods like celery (choice A), green salad (choice B), and green peas (choice C) can worsen symptoms by irritating the inflamed diverticula. Pork tenderloin (choice C) is high in fat, which can be difficult to digest. Grilled chicken breast with white rice provides protein and carbohydrates without aggravating the condition.
A patient is scheduled for biopsy of a painful tongue ulcer. Based on knowledge of risk factors for oral cancer
- A. what should the nurse specifically ask the patient about during a history?
- B. Excessive exposure to sunlight
- C. Recurrent herpes simplex infections
- D. Use of any type of tobacco products
Correct Answer: C
Rationale: Tobacco use is a major risk factor for oral cancer, so it is crucial to ask the patient about their smoking or chewing habits.
Which of the following is critical in terms of triggering a fever response?
- A. an infection
- B. a local widening of blood vessels
- C. activation of the complement system
- D. the resetting of the body's temperature set point in the hypothalamus
Correct Answer: D
Rationale: The correct answer is D because the hypothalamus acts as the body's thermostat and controls temperature regulation. When the body detects an infection or other triggers, the hypothalamus resets the temperature set point higher, causing a fever response to help fight off the infection. Choices A, B, and C are incorrect because while an infection can trigger a fever response, it is the hypothalamus that ultimately controls and initiates the response by resetting the temperature set point, not a local widening of blood vessels or activation of the complement system.
A 20-yr-old woman is being admitted with electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider?
- A. The patient uses laxatives daily.
- B. The patient's knuckles are macerate
- D. The patient's serum potassium level is 2.9 mEq/L.
Correct Answer: D
Rationale: The correct answer is D. A serum potassium level of 2.9 mEq/L indicates hypokalemia, which can be life-threatening. Hypokalemia can lead to cardiac arrhythmias and muscle weakness. It is crucial to report this finding promptly to the healthcare provider for immediate intervention. Choice A is relevant but not as urgent as hypokalemia. Choice B is unrelated to electrolyte disorders. Choice C is incomplete and does not provide any relevant information.
Patients with gastric ulcer typically exhibit the following symptoms:
- A. Epigastric pain worse after eating and weight loss.
- B. Epigastric pain worse before meals, pain awakening patient from sleep, and melena.
- C. Decreased bowel sounds, rigid abdomen, rebound tenderness, and fever.
- D. Boring epigastric pain radiating to back and left shoulder, bluish-gray discoloration of periumbilical area, and ascites.
Correct Answer: B
Rationale: Gastric ulcers typically present with epigastric pain that worsens before meals, pain that can wake the patient at night, and melena due to gastrointestinal bleeding.