Nokea
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
- A. A loss of phagocytic activity
- B. Faulty processing of bilirubin
- C. Enhanced detoxification of drugs
- D. The formation of collateral circulation
Correct Answer: B
Rationale: A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. The faulty processing of bilirubin produces bile salts, which are irritating to the skin. The detoxification of drugs is impaired with cirrhosis of the liver. Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
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The nurse is teaching a client with a history of GERD about dietary modifications. The nurse should tell the client to avoid:
- A. Spicy foods
- B. High-fiber foods
- C. Lean proteins
- D. Fresh fruits
Correct Answer: A
Rationale: Spicy foods can irritate the esophagus and relax the lower esophageal sphincter, worsening GERD symptoms, so they should be avoided.
The nurse is assessing a client with suspected diabetic ketoacidosis. Which finding is most expected?
- A. Kussmaul respirations
- B. Hypertension
- C. Bradycardia
- D. Clear breath sounds
Correct Answer: A
Rationale: Kussmaul respirations (rapid, deep breathing) are a compensatory mechanism in diabetic ketoacidosis to eliminate excess carbon dioxide and correct acidosis. Hypotension, tachycardia, and clear breath sounds are more common.
The nurse is caring for a client with a history of hypothyroidism. The nurse should expect the client to have:
- A. Fatigue
- B. Tachycardia
- C. Weight loss
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, causing fatigue, weight gain, and cold intolerance.
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Anorexia nervosa is often linked to issues of control and identity; activities fostering self-identity help address underlying psychological factors.
The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client's treatment, the nurse should:
- A. Limit the number of visitors.
- B. Provide a low-protein diet.
- C. Discuss the possibility of dialysis.
- D. Offer the client additional fluids.
Correct Answer: D
Rationale: Nephrotic syndrome causes edema due to protein loss, requiring fluid management. Offering additional fluids is inappropriate unless prescribed, as it may worsen edema. Visitors, diet, and dialysis depend on specific orders.