Nokea
Nurse Amy teaches a group of nursing students about the factors that cuses biliary cirrhosis. Which factor is associated with the condition?
- A. acute viral hepatitis
- B. alcohol hepatotoxicity
- C. chronic biliary inflammation or obstruction
- D. hepatic failure with prolonged venous hepatic congestion
Correct Answer: C
Rationale: The correct answer is C: chronic biliary inflammation or obstruction. Biliary cirrhosis is a condition characterized by scarring of the liver due to long-term damage to the bile ducts. Chronic biliary inflammation or obstruction can lead to the build-up of bile in the liver, causing damage over time. Acute viral hepatitis (choice A) typically does not directly cause biliary cirrhosis. Alcohol hepatotoxicity (choice B) is more commonly associated with alcoholic liver disease rather than biliary cirrhosis. Hepatic failure with prolonged venous hepatic congestion (choice D) may lead to liver cirrhosis, but it is not specific to biliary cirrhosis.
You may also like to solve these questions
A home care nurse assesses for disease complications in a client with bone cancer. The nurse knows that bone cancer may cause which electrolyte disturbance?
- A. Hyperkalemia
- B. Hyponatremia
- C. Hypercalcemia
- D. hypomagnesemia
Correct Answer: C
Rationale: The correct answer is C: Hypercalcemia. In bone cancer, there can be excessive release of calcium from the bones, leading to elevated blood calcium levels. This can result in various complications such as kidney stones, cardiac arrhythmias, and weakness. Hyperkalemia (choice A) is not commonly associated with bone cancer. Hyponatremia (choice B) is more commonly seen in conditions like heart failure or kidney disease. Hypomagnesemia (choice D) is not a common electrolyte disturbance in bone cancer.
What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The correct answer is B: Do not stop medication abruptly. Abruptly stopping propranolol can lead to rebound hypertension and potentially life-threatening complications. The nurse should emphasize the importance of gradual tapering under medical supervision to avoid adverse effects.
A: Having potassium levels checked is not directly related to propranolol use for hypertension management.
C: Changes in appetite are not specific to propranolol use and may not be a significant concern compared to abrupt cessation of the medication.
D: Resuming usual daily activities is important but not as crucial as the correct instruction to avoid abrupt discontinuation of propranolol.
A client with lung cancer develops Homer’s when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:
- A. Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
- B. Chest pain, dyspnea, cough, weight loss, and fever.
- C. Arm and shoulder pain and atrophy of arm and hand muscles both on the affected side.
- D. Hoarseness and dysphagia.
Correct Answer: A
Rationale: The correct answer is A: Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. This is indicative of Horner's syndrome, which occurs due to the disruption of sympathetic nerve supply. Miosis (constricted pupil), ptosis (drooping eyelid), and anhidrosis (lack of sweating) are classic signs of Horner's syndrome. These symptoms occur when the tumor invades the ribs and affects the sympathetic nerve ganglia.
Summary of other choices:
B: Chest pain, dyspnea, cough, weight loss, and fever are more commonly associated with lung cancer but not specific to Horner's syndrome.
C: Arm and shoulder pain and atrophy of arm and hand muscles are not typical signs of Horner's syndrome.
D: Hoarseness and dysphagia are more common symptoms of compression of the recurrent laryngeal nerve, not Horner's syndrome.
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: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.
A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?
- A. Keep all side rails down at all times.
- B. Encourage patient to remain in bed most of the shift.
- C. Place patient in room away from the nurses’ station if possible.
- D. Assist patient into and out of bed every 4 hours or as tolerated.
Correct Answer: D
Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support.
A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls.
B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls.
C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies.
In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.