Nokea
During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.
- A. Compare current mental status to previous findings
- B. Encourage the client to ambulate in the hallway
- C. Hold the client's morning dose of lactulose
- D. Monitor the client's ammonia level
- E. Observe the client's hand movements with the arms extended
Correct Answer: A,D,E
Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.
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The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?
- A. A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then
- B. Did you ask the HCP why it is being reported?
- C. Reporting your child’s injuries is required by law. It is for your child’s safety and protection
- D. Your explanation of your child’s injuries does not seem plausible
Correct Answer: C
Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.
The nurse is caring for a client with a fiberglass cast applied to a distal fracture of the right tibia. The client should be able to bear weight on the cast within:
- A. 10 minutes
- B. 30 minutes
- C. 3 hours
- D. 24 hours
Correct Answer: D
Rationale: Fiberglass casts typically require 24 hours to fully dry and harden before weight-bearing. Choices A, B, and C are too short for the cast to achieve sufficient strength.
Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?
- A. Limit the client's activity.
- B. Encourage a high-carbohydrate diet.
- C. Utilize an incentive spirometer to improve respiratory function.
- D. Encourage fluids.
Correct Answer: D
Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.
The obstetric client is determined to have oligohydramnios. Which fetal anomaly is associated with oligohydramnios?
- A. Diabetes
- B. Renal agenesis
- C. Tracheo-esophageal fistula
- D. Tracheo-esophageal atresia
Correct Answer: B
Rationale: Oligohydramnios, low amniotic fluid, is strongly associated with renal agenesis, as the fetus's kidneys fail to produce urine, a major component of amniotic fluid. Other anomalies listed are less directly related.
A client with schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. A suitable activity for a client with schizophrenia who is experiencing auditory hallucinations is:
- A. Watching a movie with other clients
- B. Working on a large-piece puzzle
- C. Playing a game of solitaire
- D. Taking a walk with the nurse
Correct Answer: D
Rationale: Taking a walk with the nurse provides distraction and support, reducing focus on hallucinations. Group activities or solitary tasks (B, C) may be overwhelming or less therapeutic.