Nokea
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.
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Which of the following is a nurse patient care role in the preoperative phase?
- A. Obtaining preoperative orders
- B. Offering emotional support
- C. Explaining the surgical procedure
- D. Providing informed consent
Correct Answer: B
Rationale: The correct answer is B: Offering emotional support. In the preoperative phase, a nurse's role includes comforting and reassuring the patient to reduce anxiety and promote emotional well-being. This is crucial for the patient's overall experience and can positively impact their recovery. Obtaining preoperative orders (A) is typically the responsibility of the physician. Explaining the surgical procedure (C) is usually done by the surgeon. Providing informed consent (D) involves ensuring the patient understands the risks and benefits of the procedure, which is typically the responsibility of the healthcare provider performing the procedure.
Postural Hypotension is A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
- A. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
- B. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
- C. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
Correct Answer: A
Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension.
Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.
What is the nurse’s firstaction?
- A. Follow the clinical protocol for a stroke.
- B. Review the most recent lab results for the patient’s potassium level. Assess the patient for other symptoms or problems, and then notify the health care
- C. provider. Administer an antihypertensive medication from the stock supply, and then notify the
- D. health care provider.
Correct Answer: B
Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.
Which of the ff. would the nurse explain to a patient is the main purpose of a hearing aid?
- A. Amplify background noise
- B. Amplify musical sounds
- C. Occlude the ear
- D. Improve ability to hear
Correct Answer: D
Rationale: The correct answer is D: Improve ability to hear. A hearing aid is designed to improve a person's ability to hear by amplifying sound. This helps individuals with hearing loss to better understand speech and sounds in their environment.
A: Amplifying background noise is not the main purpose of a hearing aid. It may actually hinder the user's ability to focus on important sounds.
B: Amplifying musical sounds is not the primary function of a hearing aid. The main focus is on improving speech understanding.
C: Occluding the ear is not the purpose of a hearing aid. It is meant to enhance hearing, not block sound.
The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?
- A. “Be sure to take glipizide 30 minutes before meals.”
- B. “Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked monthly.”
- C. “You won’t need to check you blood glucose level after you start taking glipizide.”
- D. “Take glipizide after a metal to prevent heartburn.”
Correct Answer: A
Rationale: The correct answer is A: “Be sure to take glipizide 30 minutes before meals.” This instruction is correct because glipizide is an oral antidiabetic agent that works best when taken before meals to help control blood glucose levels. Taking it before meals allows the medication to coincide with the body's natural insulin response to food intake, thereby improving its effectiveness.
Choice B is incorrect because glipizide does not typically cause low serum sodium levels, so there is no need for monthly sodium level checks. Choice C is incorrect because it is essential for the client to continue monitoring their blood glucose levels even after starting glipizide to ensure the medication is working effectively. Choice D is incorrect because taking glipizide after a meal will not optimize its effectiveness in controlling blood glucose levels.