A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?
- A. Clay-colored stools.
- B. Hypertension.
- C. Stridor.
- D. Elevated temperature.
Correct Answer: A
Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.
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A client who has a new prescription for levothyroxine is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. I will need to take this medication for 3 months.
- B. I will take this medication with an antacid.
- C. I will avoid foods that contain iodine.
- D. I will take this medication in the morning before breakfast.
Correct Answer: D
Rationale: The correct answer is D: "I will take this medication in the morning before breakfast." Levothyroxine should be taken in the morning before breakfast to improve absorption and effectiveness. Choice A is incorrect because the duration of levothyroxine therapy is usually long-term and not limited to 3 months. Choice B is incorrect because levothyroxine should not be taken with antacids as they may decrease its absorption. Choice C is incorrect because there is no need to avoid foods that contain iodine while taking levothyroxine.
A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. I will monitor my blood sugar level once a week.
- B. I will exercise every day even if my blood sugar is low.
- C. I will eat snacks rich in carbohydrates if my blood sugar drops.
- D. I will avoid sugary foods to prevent my blood sugar from rising.
Correct Answer: C
Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.
A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?
- A. Does the doctor know you are eating that?
- B. Why are you eating seaweed soup?
- C. Of course, I will heat that up for you.
- D. The hospital food is more nutritious.
Correct Answer: C
Rationale: Respecting cultural preferences promotes trust and client-centered care.
A client is experiencing a panic attack. Which of the following actions should the nurse take first?
- A. Instruct the client to take deep, slow breaths.
- B. Administer an anti-anxiety medication.
- C. Remain with the client and offer reassurance.
- D. Encourage the client to use distraction techniques.
Correct Answer: C
Rationale: During a panic attack, the priority action for the nurse is to remain with the client and offer reassurance. This helps provide a sense of safety and security, which can aid in reducing the client's anxiety. Instructing the client to take deep, slow breaths (Choice A) can be beneficial but should come after providing immediate support. Administering medication (Choice B) should not be the first intervention unless deemed necessary by the healthcare provider. Encouraging distraction techniques (Choice D) may not be as effective initially as providing direct support and reassurance.
A client has a hemoglobin level of 7 g/dL. Which of the following findings should the nurse expect?
- A. Bounding pulses
- B. Elevated blood pressure
- C. Headache
- D. Pale, cool skin
Correct Answer: D
Rationale: Pale, cool skin is a common finding in clients with a hemoglobin level of 7 g/dL due to decreased oxygen carrying capacity. Bounding pulses (Choice A) are not typically associated with low hemoglobin levels. Elevated blood pressure (Choice B) is not a common finding in clients with anemia. While headache (Choice C) can occur with anemia, it is not a specific finding directly related to a hemoglobin level of 7 g/dL.
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