Nokea
A patient with a history of cirrhosis is at risk for developing hepatic encephalopathy. Which nursing intervention is most effective in preventing and managing hepatic encephalopathy?
- A. Administering lactulose as prescribed
- B. Restricting dietary protein intake
- C. Monitoring serum ammonia levels
- D. Encouraging increased fluid intake
Correct Answer: A
Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.
You may also like to solve these questions
Nurse Rica is in charge of the animal bite program of the health center, which of the following is the causative agent of rabies?
- A. Parasite
- B. Bacteria
- C. Virus
- D. Fungi
Correct Answer: C
Rationale: Rabies is a viral disease that affects the central nervous system. It is primarily transmitted through the bite of an infected animal, such as dogs, bats, raccoons, and foxes. The causative agent of rabies is the rabies virus, specifically from the genus Lyssavirus. Once the virus enters the body, it spreads through the nervous system to the brain, leading to severe neurological symptoms and, if left untreated, is almost always fatal. This is why prompt medical attention and vaccination following an animal bite are crucial in preventing the development of rabies in humans.
A nurse is participating in a healthcare team meeting to discuss a patient's care plan. What is the nurse's role in interdisciplinary collaboration?
- A. Dictating decisions and delegating tasks to other team members
- B. Listening actively, contributing expertise, and sharing information
- C. Assuming a passive role and deferring to other healthcare providers
- D. Working independently without considering input from other team members
Correct Answer: B
Rationale: The nurse's role in interdisciplinary collaboration is crucial for providing comprehensive and effective patient care. By actively participating in healthcare team meetings, the nurse should listen attentively to the input of other team members, contribute their expertise, and share relevant information about the patient's condition. Collaboration involves working together towards shared goals, pooling knowledge and resources, and fostering mutual respect among team members. The nurse's active involvement in the care planning process helps ensure coordinated and patient-centered care delivery. This approach enhances communication, improves outcomes, and promotes a holistic approach to patient care.
A patient with cystic fibrosis (CF) presents with recurrent pulmonary exacerbations characterized by increased sputum production, cough, and fever. Which of the following treatments is most effective for addressing the underlying pathophysiology of CF and preventing disease progression?
- A. Inhaled corticosteroids
- B. Mucolytic agents (e.g., dornase alfa)
- C. Antibiotic therapy for respiratory infections
- D. Lung transplantation
Correct Answer: B
Rationale: The most effective treatment for addressing the underlying pathophysiology of cystic fibrosis (CF) and preventing disease progression is the use of mucolytic agents, such as dornase alfa. CF is a genetic disorder that leads to the production of thick, sticky mucus in the respiratory tract. This mucus buildup can obstruct airways, lead to recurrent infections, and contribute to pulmonary exacerbations. Mucolytic agents work by reducing the viscosity of the mucus, making it easier to clear from the airways. This helps to improve lung function, reduce the frequency of exacerbations, and slow down disease progression in CF patients. Inhaled corticosteroids may be used for managing airway inflammation, but they do not target the underlying mucus production in CF. Antibiotic therapy is important for treating respiratory infections in CF patients, but it does not address the primary
A patient with a history of Hodgkin lymphoma presents with fever, chills, and generalized malaise. Laboratory tests reveal pancytopenia, circulating Reed-Sternberg cells, and bone marrow involvement. Which of the following conditions is most likely to cause these findings?
- A. Autoimmune hemolytic anemia (AIHA)
- B. Myelodysplastic syndrome (MDS)
- C. Aplastic anemia
- D. Paraneoplastic syndrome
Correct Answer: D
Rationale: The patient is presenting with symptoms and laboratory findings consistent with a paraneoplastic syndrome related to Hodgkin lymphoma. In this case, the fever, chills, generalized malaise, pancytopenia, circulating Reed-Sternberg cells, and bone marrow involvement are all indicative of a paraneoplastic syndrome associated with Hodgkin lymphoma. Paraneoplastic syndromes are a group of disorders that are triggered by an abnormal immune response to a neoplasm, such as Hodgkin lymphoma, leading to various systemic manifestations.
A patient with advanced dementia is no longer able to communicate verbally and displays signs of distress. What should the palliative nurse consider when assessing and managing the patient's distress?
- A. Focus solely on physical comfort measures to alleviate distress.
- B. Assume the patient's distress is solely related to physical discomfort.
- C. Explore non-verbal cues and behaviors to identify the underlying causes of distress.
- D. Administer sedative medications to manage the patient's agitation.
Correct Answer: C
Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.