Nokea
A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
- A. Assess for GI bleeding.
- B. Hold the Lactulose (Cephulac).
- C. Increase protein in the diet.
- D. Monitor serum bilirubin levels.
Correct Answer: A
Rationale: Confusion and asterixis indicate hepatic encephalopathy, often precipitated by GI bleeding (A), which increases ammonia levels. Holding lactulose (B) is incorrect as it reduces ammonia. Increasing protein (C) worsens encephalopathy. Bilirubin (D) is unrelated to acute symptoms.
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Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's:
- A. Decreased cellular demand for oxygen.
- B. Reduced episodes of coughing.
- C. Diminished pain when breathing deeply.
- D. Ability to expectorate secretions more easily.
Correct Answer: A
Rationale: Bed rest reduces oxygen demand by decreasing metabolic rate, aiding recovery in pneumonia. Reduced coughing, diminished pain, and easier expectoration are secondary benefits but not the primary measure of bed rest effectiveness.
The rapid response team has been called to manage an unwitnessed cardiac arrest. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is:
- A. 1 to 2 minutes.
- B. 4 to 6 minutes.
- C. 8 to 10 minutes.
- D. 12 to 15 minutes.
Correct Answer: B
Rationale: Brain damage begins after 4 to 6 minutes without oxygenation, making this the critical window for initiating CPR to prevent permanent damage.
Which of the following therapeutic classes of drugs is used to treat tachycardia and angina in a client with pheochromocytoma?
- A. Angiotensin-converting enzyme (ACE) inhibitors.
- B. Calcium channel blockers.
- C. Beta blockers.
- D. Diuretics.
Correct Answer: C
Rationale: Beta blockers reduce tachycardia and angina in pheochromocytoma by blocking catecholamine effects on the heart.
Which of the following describes decerebrate posturing?
- A. Internal rotation and adduction of arms with the excess, wrists, and fingers.
- B. Back hunched with the position of all four extremities with supination of arms and plantar flexion of feet.
- C. Supination of arms, dorsiflexion of the feet.
- D. Back arched, rigid extension of all four extremities.
Correct Answer: D
Rationale: Decerebrate posturing involves rigid extension of all extremities with arched back, indicating severe brain stem dysfunction. The other options describe decorticate posturing or incorrect combinations of movements.
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.