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A client with hepatitis C is scheduled for a liver biopsy. Which would the nurse include in the teaching plan?
- A. The client should lie on the left side after the procedure.
- B. Cleansing enemas should be given the morning of the procedure.
- C. Blood coagulation studies might be done before the biopsy.
- D. The procedure is noninvasive and causes no pain.
Correct Answer: C
Rationale: Hepatitis C increases bleeding risk, so coagulation studies are done before a liver biopsy to ensure safety. The client lies on the right side post-procedure, enemas aren't needed, and the procedure is invasive with some pain.
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The nurse is caring for a client with depression over the recent death of her father from cancer. The client states, 'It's my fault. I should have insisted he get regular checkups instead of letting him put it off.' The nurse responds, 'You feel like it's your fault?' Which therapeutic communication technique is the nurse using?
- A. exploring
- B. reflecting
- C. restating
- D. focusing
Correct Answer: B
Rationale: Reflecting mirrors the client’s feelings, encouraging further expression and exploration of emotions.
A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
- A. Currant jelly stools
- B. Projectile vomiting
- C. Ribbonlike stools
- D. Palpable mass over the flank
Correct Answer: A
Rationale: Currant jelly stools, caused by blood and mucus, are a hallmark of intussusception due to intestinal obstruction.
The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
- A. provide positive feedback
- B. place hygiene items on the client's left side
- C. provide assistive devices
- D. assess abilities and level of deficit
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.
Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:
- A. Pieces of hot dog
- B. Carrot sticks
- C. Pieces of cereal
- D. Raisins
Correct Answer: C
Rationale: Cereal pieces are soft, safe, and promote chewing without the choking risk posed by hot dogs, carrots, or sticky raisins in toddlers.
The nurse caring for a client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/L
- B. Calcium 13 mg/dL
- C. Inorganic phosphorus 1.7 mEq/L
- D. Sodium 138 mEq/L
Correct Answer: B
Rationale: Bone metastasis often causes hypercalcemia (calcium 13 mg/dL is elevated), leading to confusion and hypertension. The other values are normal or unrelated.