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Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?
- A. carbon dioxide level
- B. prothrombin time
- C. gastric pH
- D. white blood cell count
Correct Answer: B
Rationale: Liver cirrhosis affects the liver's ability to produce proteins that are important for blood clotting, including prothrombin. Therefore, in a patient with liver cirrhosis, Nurse Bea would expect an alteration in the prothrombin time, which measures the time it takes for the blood to clot. A prolonged prothrombin time indicates impaired blood clotting function, which is commonly seen in patients with liver disease such as cirrhosis. It is an important laboratory value to monitor in patients with liver cirrhosis to assess their risk of bleeding complications.
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Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
- A. "What would you like to do first, brush your teeth?"
- B. "Where is y our toothbrush?"
- C. "When would you like to have your bath?"
- D. "Would you like to brush your teeth, or do you want me to do it for you? it's good to do things for yourself."
Correct Answer: D
Rationale: Option D is the most appropriate statement when assisting a patient with altered thought process and personal hygiene needs. This statement provides the patient with a choice between brushing their teeth independently or having assistance, while also emphasizing the importance of self-care activities. Offering patients choices empowers them and helps maintain their sense of autonomy, even when dealing with altered thought processes. Additionally, encouraging patients to perform activities for themselves can help improve their self-esteem and promote independence.
Patient S is a sexually active adolescent; which of the following instructions would be included in the preventive teaching plan about urinary tract infections?
- A. Drinking acidic juices
- B. Avoiding urinating before intercourse
- C. Wearing nylon underwear
- D. Wiping back to front
Correct Answer: A
Rationale: Drinking acidic juices, such as cranberry juice, can help make the urine more acidic, which can potentially prevent bacteria from sticking to the urinary tract walls and reduce the risk of urinary tract infections. It is important to note that while acidic juices can be beneficial in some cases, they should not be relied upon as the sole preventive measure for UTIs. Other important preventive measures include staying hydrated, practicing good hygiene, and urinating before and after intercourse.
A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse's BEST response?
- A. move the right crutch ahead, then follow with the left foot
- B. move both crutches forward together, then swing legs through
- C. move the left crutch and the right foot forward together
- D. move both crutches and the weaker leg forward at the same time
Correct Answer: A
Rationale: In the four-point gait when partial weight bearing is permitted, the correct technique is to move the right crutch ahead, then follow with the left foot. This technique provides the most stability and support for the individual while allowing for proper weight distribution and balance. Moving the crutches and legs in a coordinated fashion helps prevent falls and ensures the safe ambulation of the client.
Which is the most reliable method for monitoring fluid balance?
- A. Daily intake and output
- B. Vital signs
- C. Daily weight
- D. Skin turgor
Correct Answer: A
Rationale: Monitoring daily intake and output is the most reliable method for assessing fluid balance in a patient. By accurately measuring the amount of fluids taken in through foods, drinks, and IV fluids, as well as the amount of fluids eliminated through urine, stool, vomit, and other means, healthcare providers can closely track the body's fluid balance. Discrepancies between intake and output can indicate potential issues such as dehydration or fluid overload. This method provides quantitative data that can guide appropriate interventions and treatment adjustments to maintain the patient's fluid balance within normal limits. While vital signs, daily weight, and skin turgor are also important indicators of fluid status, they may not always provide as specific or accurate information as the direct measurement of intake and output.
Failure to thrive (FTT) is a descriptive term given to malnourished infants and young children who fail to meet expected standards of growth. Of the following, the growth parameter that is usually not affected by malnutrition is
- A. weight
- B. height
- C. weight for height ratio
- D. head circumference
Correct Answer: D
Rationale: Head circumference is less likely to be affected by short-term malnutrition because brain growth is prioritized during infancy and early childhood.