Nokea
A client with cirrhosis of the liver is experiencing ascites. The nurse should implement which of the following interventions?
- A. Restrict fluid intake
- B. Increase sodium intake
- C. Encourage high-protein diet
- D. Administer diuretics
Correct Answer: D
Rationale: Corrected Rationale: Ascites, the accumulation of fluid in the abdominal cavity, is a common complication of cirrhosis. Diuretics are the primary intervention to manage ascites by promoting the excretion of excess fluid from the body, thus reducing abdominal swelling. Restricting fluid intake (Choice A) would not be appropriate as it may lead to dehydration. Increasing sodium intake (Choice B) is contraindicated as it can worsen fluid retention. Encouraging a high-protein diet (Choice C) is not directly related to managing ascites.
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The multidisciplinary home health care team is discussing a female client diagnosed with Parkinson's disease. The home health care nurse reports the client is getting worse, and her husband is no longer able to care for her in the home. Which action should the home health nurse implement first?
- A. Request a chaplain to counsel the couple.
- B. Assign a home health care aide to provide daily care.
- C. Discuss placing the wife in a nursing home with the husband.
- D. Contact the client's children to discuss the situation.
Correct Answer: B
Rationale: In situations where a client's condition worsens and the caregiver is no longer able to provide sufficient care, the first action to implement is to assign a home health care aide to provide daily care. This ensures that the client's immediate needs are met and that they receive proper care and support. Requesting a chaplain for counseling (Choice A) may be beneficial but is not the most urgent action. Discussing placing the wife in a nursing home (Choice C) should only be considered after assessing the client's needs and exploring all other options. Contacting the client's children (Choice D) can be helpful but does not address the immediate need for daily care that the client requires.
A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:
- A. Increase acid secretion
- B. Reduce acid secretion
- C. Promote gastric emptying
- D. Remove the ulcerated area
Correct Answer: B
Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.
Following-up Mrs. Luy, G5P4, you notice her eldest son is underweight and her youngest daughter looks thin and pale. Mrs. Luy's present pregnancy would mean another additional member of the family. This can be considered as:
- A. health deficit
- B. health deficit and health threat
- C. health threat
- D. foreseeable crisis
Correct Answer: C
Rationale: The correct answer is C: 'health threat.' The new pregnancy poses a health threat due to the potential strain on resources and the existing issues with the children, such as underweight and being pale. Choice A is incorrect as it does not fully capture the potential risks associated with the new pregnancy. Choice B is also incorrect as it includes 'health deficit,' which is not explicitly mentioned in the scenario. Choice D, 'foreseeable crisis,' is not the most fitting description of the situation presented.
Occupational health nursing is concerned with the following except:
- A. educating workers about health
- B. immediate diagnosis of illness prevailing in the work field
- C. appropriate and effective ways of promoting health
- D. planning of administering health services
Correct Answer: B
Rationale: Occupational health nursing focuses on educating workers about health, promoting health through appropriate and effective ways, and planning and administering health services in the workplace. Immediate diagnosis of illness prevailing in the work field is typically not the primary role of occupational health nursing, as it usually involves prevention, education, and health promotion rather than diagnosing acute conditions.
What is the FIRST STEP for thermal protection of a newborn?
- A. Drying the baby thoroughly immediately after birth
- B. Covering the baby with a clean, dry cloth after the cord has been cut
- C. Drying the baby thoroughly after the cord has been cut
- D. Covering the baby with a clean, dry cloth immediately after birth
Correct Answer: A
Rationale: The correct first step for thermal protection of a newborn is to dry the baby thoroughly immediately after birth. This helps prevent heat loss and is crucial in maintaining the baby's body temperature. Choice B, covering the baby with a clean, dry cloth after the cord has been cut, is not the initial step as drying the baby comes first. Choice C, drying the baby thoroughly after the cord has been cut, is also not the first step. Choice D, covering the baby with a clean, dry cloth immediately after birth, is not as effective as drying the baby to prevent heat loss.