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In a client with liver cirrhosis experiencing confusion and disorientation, what condition is most likely causing these symptoms?
- A. Hepatic encephalopathy
- B. Hypoglycemia
- C. Electrolyte imbalance
- D. Dehydration
Correct Answer: A
Rationale: The correct answer is A: Hepatic encephalopathy. In liver cirrhosis, the liver's ability to detoxify ammonia is impaired, leading to elevated ammonia levels in the blood. This excess ammonia crosses the blood-brain barrier, causing neurological symptoms like confusion and disorientation. Hypoglycemia (B), electrolyte imbalance (C), and dehydration (D) can also contribute to altered mental status, but in a cirrhotic patient, hepatic encephalopathy is the most likely cause due to impaired ammonia metabolism.
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The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?
- A. The mother who took her children from school because aliens were after them.
- B. The young man who has a history of substance abuse and no telephone.
- C. The newly diagnosed client who needs to be evaluated for medication compliance.
- D. The young woman who believes she is to blame for her recent miscarriage.
Correct Answer: A
Rationale: The correct answer is A: The mother who took her children from school because aliens were after them should be seen first. This choice indicates potential harm to the children due to the mother's delusions, posing an immediate safety concern. The nurse needs to assess the situation and ensure the children's safety. Choices B, C, and D do not present immediate safety risks. B is a history of substance abuse but no current immediate danger. C is newly diagnosed and can wait for evaluation, as can D who may need support but is not in immediate danger. Prioritizing safety is crucial in mental health nursing.
What is the most appropriate nursing intervention to help alleviate severe abdominal pain in a patient with acute pancreatitis?
- A. Encourage oral intake of clear fluids.
- B. Place the patient in a supine position.
- C. Administer prescribed opioid analgesics.
- D. Apply a heating pad to the abdomen.
Correct Answer: C
Rationale: The correct answer is C, administering prescribed opioid analgesics. This intervention is appropriate for severe abdominal pain in acute pancreatitis as opioids are effective in managing pain. Encouraging oral intake (A) can worsen symptoms, a supine position (B) can exacerbate pain, and a heating pad (D) can aggravate inflammation. Administering opioid analgesics provides direct pain relief and is the most effective intervention for alleviating severe abdominal pain in acute pancreatitis.
A patient with heart failure is prescribed digoxin. What is the most important instruction the nurse should provide?
- A. Take an extra dose if you miss one.
- B. Avoid high-potassium foods.
- C. Report any visual disturbances.
- D. Stop taking the medication if your pulse is normal.
Correct Answer: C
Rationale: The correct answer is C: Report any visual disturbances. This is important because digoxin can cause visual disturbances, such as blurred or yellow-tinted vision, which may indicate toxicity. By reporting these symptoms promptly, the nurse can prevent serious complications.
A: Taking an extra dose if a dose is missed can lead to overdose and toxicity.
B: Avoiding high-potassium foods is important for patients taking potassium-sparing diuretics, not digoxin.
D: Stopping the medication if the pulse is normal is incorrect as it should be taken as prescribed for heart failure management.
A patient with bipolar disorder is prescribed lithium. What dietary advice should the nurse provide?
- A. Increase intake of caffeine.
- B. Maintain a consistent salt intake.
- C. Avoid dairy products.
- D. Increase intake of green leafy vegetables.
Correct Answer: B
Rationale: The correct answer is B: Maintain a consistent salt intake. Lithium can affect sodium levels in the body, so it's important to maintain a consistent salt intake to prevent lithium toxicity or imbalance. Increasing caffeine intake (choice A) can worsen symptoms of bipolar disorder. Avoiding dairy products (choice C) is not necessary for lithium therapy. Increasing intake of green leafy vegetables (choice D) is generally healthy but not specifically recommended for lithium therapy. Maintaining a consistent salt intake is crucial in managing the effects of lithium on sodium levels.
A patient with a myocardial infarction (MI) is being treated with intravenous morphine. What is the primary reason for administering morphine to this patient?
- A. To reduce pain.
- B. To decrease anxiety.
- C. To reduce cardiac workload.
- D. To increase respiratory rate.
Correct Answer: C
Rationale: The primary reason for administering morphine to a patient with MI is to reduce cardiac workload. Morphine acts as a vasodilator and decreases preload and afterload on the heart, reducing myocardial oxygen demand. This helps to improve coronary blood flow and decrease the workload on the heart muscle, which is crucial in the setting of an MI.
Explanation for other choices:
A: While morphine can help reduce pain in MI, the primary reason for administering it is to reduce cardiac workload.
B: Morphine may have a calming effect, but the primary goal is to reduce cardiac workload.
D: Morphine can actually decrease respiratory rate as a side effect, making this choice incorrect.