Nokea
A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: Cirrhosis impairs the liver's ability to metabolize ammonia, leading to elevated levels and risk of hepatic encephalopathy. The other conditions do not directly affect ammonia levels. Reduction of Risk Potential
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A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the
- A. Yang, the positive force that represents light, warmth, and fullness
- B. Yin, the negative force that represents darkness, cold, and emptiness
- C. Use of improper hot foods, herbs and plants
- D. A failure to keep life in balance with nature and others
Correct Answer: B
Rationale: Yin, the negative force that represents darkness, cold, and emptiness. Excessive Yin is believed to cause illness in Chinese folk medicine.
Right documentation includes the name, dosage, route, and time of administration. When should you sign your initials on the medication administration record?
- A. Immediately before the dose is given
- B. Immediately after the dose has been given
- C. Immediately before the dose is given, in the medication room
- D. Within one hour after administering the medication
Correct Answer: B
Rationale: Signing immediately after administration confirms the dose was given, ensuring accurate documentation. Signing before risks errors, and waiting an hour delays accuracy.
An adult is to go to surgery this morning. When the nurse goes to medicate the client, she notes that she has a ring with several shiny stones in it on her left ring finger. There are no relatives present. What is the best nursing action?
- A. Tape the ring before medicating the client.
- B. Ask the client to put the ring in the bedside drawer.
- C. Label the ring and place it in an envelope in the hospital safe.
- D. Have the client sign a waiver regarding responsibility for the ring.
Correct Answer: C
Rationale: Securing valuables in the hospital safe protects the ring during surgery, adhering to safety protocols. Taping, bedside storage, or waivers risk loss.
The nurse is assessing a client with a suspected fracture of the radius. Which of the following findings would support this diagnosis?
- A. Swelling and deformity at the wrist.
- B. Pain in the shoulder with movement.
- C. Numbness in the lower leg.
- D. Fever and joint stiffness.
Correct Answer: A
Rationale: A radius fracture typically causes swelling and deformity at the wrist due to bone disruption. Shoulder pain (B) suggests a proximal injury, leg numbness (C) is unrelated, and fever/stiffness (D) indicate infection or arthritis.
In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:
- A. hypothyroidism
- B. hyperglycemia
- C. hypertension
- D. antiseizure medication
Correct Answer: A
Rationale: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.