Nokea
A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now taste 'bitter'. He complains that he simply has no appetite. What action should the nurse implement?
- A. Suggest the use of alternative sources of protein such as dairy products and nuts.
- B. Encourage the client to eat smaller, more frequent meals.
- C. Offer nutritional supplements between meals.
- D. Discuss the possibility of appetite stimulants with the healthcare provider.
Correct Answer: A
Rationale: Offering alternative protein sources like dairy products and nuts can help maintain nutrition when the client finds certain foods unpalatable, as in this case where beef, chicken, and eggs taste 'bitter'. Encouraging smaller, more frequent meals may not address the issue of unpalatable foods. Offering nutritional supplements between meals may not specifically address the problem of protein intake. Discussing appetite stimulants should be considered after exploring less invasive options first.
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During the initial visit, which intervention is most important for the nurse to implement?
- A. Determine how the client is cared for when the caregiver is not present.
- B. Develop a client needs assessment and review it with the caregiver.
- C. Evaluate the caregiver's ability to care for the client's needs.
- D. Review with the caregiver the interventions provided each day.
Correct Answer: A
Rationale: The most important intervention for the nurse to implement during the initial visit is to determine how the client is cared for when the caregiver is not present. This is crucial for ensuring continuous and adequate care, especially for a bed-bound client with multiple sclerosis who relies heavily on the caregiver. While developing a client needs assessment (choice B) and evaluating the caregiver's ability (choice C) are important, understanding the care plan in the caregiver's absence takes precedence. Reviewing daily interventions with the caregiver (choice D) is valuable but not as critical as knowing the care plan during the caregiver's absence.
A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Hemoglobin
- C. White blood cell count
- D. Serum creatinine
Correct Answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium closely is essential. Erythropoietin therapy can lead to increased red blood cell production, which may cause potassium levels to rise, potentially resulting in hyperkalemia. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because they are not directly impacted by erythropoietin therapy in the context of CKD.
A client with liver cirrhosis and ascites is admitted with jaundice. Which laboratory value is most concerning to the nurse?
- A. Serum albumin of 3.0 g/dl
- B. Bilirubin of 3.0 mg/dl
- C. Ammonia level of 80 mcg/dl
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An ammonia level of 80 mcg/dl is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to neurological symptoms such as confusion, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are important in liver cirrhosis but are not the most concerning for acute neurological deterioration associated with hepatic encephalopathy.
A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab test is important for the nurse to review before contacting the healthcare provider?
- A. Capillary glucose
- B. Urine specific gravity
- C. Serum calcium
- D. White blood cell count
Correct Answer: C
Rationale: The correct answer is C: Serum calcium. Numbness and tingling in the fingers and around the mouth are indicative of hypocalcemia. Serum calcium levels should be reviewed as they play a crucial role in diagnosing and managing hypocalcemia. Option A, capillary glucose, is not relevant to the symptoms described. Option B, urine specific gravity, is not typically used to assess numbness and tingling. Option D, white blood cell count, is unrelated to the symptoms presented by the client.
A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?
- A. INR of 3.5
- B. Prothrombin time (PT) of 15 seconds
- C. Headache
- D. Blood pressure of 140/90 mmHg
Correct Answer: C
Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.