Nokea
A client with pancreatitis tells the nurse that he fears nighttime. Which of the following statements most likely relates to the client's concerns?
- A. The pain is aggravated in the recumbent position.
- B. The client has fewer distractions at night.
- C. The mattress is uncomfortable.
- D. The pain increases after a day of activity.
Correct Answer: A
Rationale: Pancreatitis pain is often worsened in the recumbent position, contributing to the client’s fear of nighttime.
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The occupational health nurse has had five (5) clients come to the clinic complaining of abdominal cramping, nausea, and vomiting. Which information should the nurse teach the employees to decrease the spread of this condition?
- A. Teach the employees to cough into the sleeve.
- B. Teach the housekeepers to use an antibacterial soap.
- C. Teach the coworkers to get a hepatitis vaccine.
- D. Teach the employees to wash their hands frequently.
Correct Answer: D
Rationale: Frequent handwashing prevents the spread of gastroenteritis, likely causing these symptoms. Coughing into sleeves, antibacterial soap, and hepatitis vaccines are less relevant.
The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.
The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney's point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response?
- A. The next time the doctor comes in, we should ask him what he meant by that.'
- B. I've felt that I don't understand the doctor at times either.'
- C. That is the term used to indicate that the pain has traveled to the right lower side.'
- D. McBurney's point refers to severe pain for which surgery is the only treatment.'
Correct Answer: C
Rationale: McBurney's point is the area in the right lower quadrant where appendicitis pain localizes, indicating inflammation of the appendix.
The client is admitted with upper right-side abdominal pain. The nurse is concerned that the client may have liver cancer when which serum laboratory test results are elevated?
- A. Creatinine and BUN
- B. α-fetoprotein (AFP)
- C. Phosphorus levels
- D. CA-125 levels
Correct Answer: B
Rationale: A. Elevated serum creatinine and BUN are associated with renal problems. B. Serum α-fetoprotein is a major serum protein synthesized by fetal liver cells, by yolk sac cells, and in small amounts by the fetal GI system. Reappearance of AFP in adults signals pathological problems. In 50% to 75% of clients with liver cancer, serum AFP levels are elevated. C. Elevated serum phosphorus is associated with renal and many other diseases and is not specific to liver cancer. D. CA-125 is a tumor marker for ovarian cancer.
The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN?
- A. Assist the UAP to learn to perform blood glucose checks.
- B. Monitor the potassium levels of a client with diarrhea.
- C. Administer a bulk laxative to a client diagnosed with constipation.
- D. Assess the abdomen of a client who has had complaints of pain.
Correct Answer: C
Rationale: Administering a laxative is within the LPN’s scope. Teaching UAPs, monitoring labs, and abdominal assessments require RN skills.