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A client with portal hypertension who has developed ascites is scheduled for a paracentesis. What pre-procedure nursing intervention is essential?
- A. Encourage the client to empty the bladder
- B. Administer a laxative to clear the bowels
- C. Restrict the client's fluid intake
- D. Place the client in a supine position
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to empty the bladder. Before a paracentesis, it's crucial to ensure the bladder is empty to prevent accidental puncture during the procedure. This reduces the risk of injury and complications. Options B and C are incorrect because they are not directly related to the safety of the paracentesis procedure. Option D is incorrect as placing the client in a supine position does not address the need to empty the bladder.
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A 40-year-old man presents with abdominal pain, diarrhea, and weight loss. He has a history of Crohn's disease. Laboratory tests reveal low hemoglobin and elevated ESR. What is the most likely diagnosis?
- A. Ulcerative colitis
- B. Irritable bowel syndrome
- C. Celiac disease
- D. Crohn's disease flare
Correct Answer: D
Rationale: The correct answer is D: Crohn's disease flare. Given the patient's history of Crohn's disease, symptoms of abdominal pain, diarrhea, weight loss, and abnormal lab findings (low hemoglobin, elevated ESR) are indicative of a flare-up of Crohn's disease. This is supported by the clinical presentation and the lab results. Ulcerative colitis (A) presents differently with rectal bleeding and mucous diarrhea. Irritable bowel syndrome (B) does not typically cause weight loss or abnormal lab findings. Celiac disease (C) would present with malabsorption symptoms and specific antibodies, not consistent with this patient's presentation. Crohn's disease flare (D) is the most likely diagnosis based on the information provided.
A 60-year-old man presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?
- A. Type 1 diabetes mellitus
- B. Type 2 diabetes mellitus
- C. Diabetes insipidus
- D. Hyperthyroidism
Correct Answer: A
Rationale: The most likely diagnosis for a 60-year-old man with fatigue, polyuria, polydipsia, hyperglycemia, and ketonuria is Type 1 diabetes mellitus. The key clues are the presence of ketonuria, which indicates the body is breaking down fats for energy due to lack of insulin in Type 1 diabetes. Additionally, the acute onset of symptoms in an older individual suggests an autoimmune destruction of pancreatic beta cells seen in Type 1 diabetes. Type 2 diabetes is less likely due to the acute presentation and ketonuria. Diabetes insipidus presents with polyuria but not hyperglycemia or ketonuria. Hyperthyroidism typically presents with symptoms such as weight loss, tremors, and heat intolerance, not the classic symptoms seen in this case.
A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?
- A. Weight gain.
- B. Dry mouth.
- C. Muscle rigidity.
- D. Drowsiness.
Correct Answer: C
Rationale: The correct answer is C: Muscle rigidity. This finding could be indicative of Neuroleptic Malignant Syndrome (NMS), a rare but serious side effect of antipsychotic medications like risperidone. NMS is characterized by severe muscle rigidity, fever, altered mental status, and autonomic dysfunction. Prompt medical intervention is crucial to prevent complications.
A: Weight gain is a common side effect of risperidone and is typically not considered an urgent issue.
B: Dry mouth is a common side effect of risperidone and can be managed with oral hygiene measures.
D: Drowsiness is a common side effect of risperidone and may improve over time or with dosage adjustments. It is not typically an immediate concern unless severe or accompanied by other worrisome symptoms.
A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?
- A. Reports reduced nasal discharge.
- B. Denies having coughing spells.
- C. Able to sleep through the night.
- D. Expectorating bronchial secretions.
Correct Answer: B
Rationale: The correct answer is B: Denies having coughing spells. Benzonatate is an antitussive medication that suppresses cough reflex. If the client denies having coughing spells, it indicates that the medication is effectively suppressing the cough. This is the most direct indicator of the medication's effectiveness.
A: Reports reduced nasal discharge - This is not directly related to the effectiveness of benzonatate in suppressing cough.
C: Able to sleep through the night - While improved sleep may result from reduced coughing, it is not as specific an indicator of antitussive effectiveness as denying coughing spells.
D: Expectorating bronchial secretions - This indicates productive coughing, which is not the intended effect of benzonatate.
A client is being educated about type 2 diabetes. The educator can confirm that the client understands the primary treatment for type 2 diabetes when the client states what?
- A. I read that a pancreas transplant will provide a cure for my diabetes.
- B. I will take my oral antidiabetic agents when my morning blood sugar is high.
- C. I will make sure to follow the weight loss plan designed by the dietitian.
- D. I will make sure I call the diabetes educator when I have questions about my insulin.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Weight loss helps improve insulin sensitivity.
2. Managing weight is crucial for controlling blood sugar levels.
3. Dietitian-designed plans focus on balanced nutrition for diabetes management.
4. Weight loss can reduce the need for medication and improve overall health.
Summary of Incorrect Choices:
A: Pancreas transplant is not a primary treatment for type 2 diabetes.
B: Taking oral antidiabetic agents based on blood sugar levels is not ideal.
D: Contacting the diabetes educator for insulin questions is important but not primary treatment.