Nokea
The 40-year-old client is recovering from an exacerbation of chronic pancreatitis. As the client prepares for discharge, the client makes several statements to the nurse. Which statement should be concerning because it could inhibit the client’s ability to accomplish the developmental tasks of middle adulthood?
- A. “I’m planning on continuing to be active in the local town service club.”
- B. “I enjoy my job; I should be able to return to work in about 3 to 4 weeks.”
- C. “I’ve missed friends and look forward to having a glass of wine with them.”
- D. “My spouse has been very supportive during my lengthy hospitalization.”
Correct Answer: C
Rationale: A. Volunteer activities meet the developmental task of middle adulthood of generativity. B. Planning to return to work meets the developmental task of middle adulthood of generativity. C. Consuming alcohol will cause continued progression of the pancreatic disease and could eventually result in the inability to work or to participate in community service. This statement should be concerning to the nurse. D. This statement indicates that the client has the support of another.
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The client tells the nurse about being diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know about the treatment. Which statement should be the basis for the nurse’s response?
- A. The use of chemotherapy is the first-line treatment for liver cancer.
- B. Liver transplantation is not an option for clients with liver cancer.
- C. Radiofrequency ablation can be successful in treating tumors of this size.
- D. A tumor of this size can only be removed through an open surgical approach.
Correct Answer: C
Rationale: A. Chemotherapy is only used for clients who are not likely to benefit from other therapies. B. Liver transplantation is used when the tumor is large or localized. C. Radiofrequency ablation is a treatment technique that uses high-frequency alternating electrical current to heat tissue cells and destroy them. It can be successfully used to treat tumors less than 5 cm in size because these tumors tend to be slow growing and encapsulated. D. Surgical resection of the tumor is used when the tumor is large or localized.
The nurse is completing the client’s hospital admission history. Which statement should prompt the nurse to further question the client about symptoms associated with GERD?
- A. “I have been experiencing headaches immediately after eating.”
- B. “Lately, I wake up at night with a burning feeling in my chest.”
- C. “I have been waking up at night sweating and wet all over.”
- D. “Immediately after eating I feel sleepy and want to go to bed.”
Correct Answer: B
Rationale: A. Headaches are a symptom not related to GERD. B. Heartburn, which is described as a burning, tight sensation in the lower sternum, is the most common symptom of GERD. It will often wake the client from sleep. C. Night sweats are a symptom not related to GERD. D. Postprandial sleepiness is a symptom not related to GERD.
The nurse is caring for the client with diverticulitis. The nurse should plan to instruct the client to avoid which food during an episode of diverticulitis?
- A. White bread
- B. Ripe banana
- C. Cooked oatmeal
- D. Iceberg lettuce
Correct Answer: C
Rationale: A. White bread is a recommended food for fiber-restricted diets. It contains less than 1 g fiber per ounce. B. Ripe bananas, canned soft fruits, and most well-cooked vegetables without seeds or skins are recommended for fiber-restricted diets. C. Cooked oatmeal contains 4 g of fiber per serving. Foods high in fiber should be avoided during an episode of diverticulitis, and foods should be restricted to low fiber or clear liquids. Once diverticulitis is resolved, the client should return to a high-fiber diet. D. Iceberg lettuce contains less than 1 g of fiber.
Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?
- A. How many years have you been drinking alcohol?
- B. Have you completed an advance directive?
- C. When did you have your last alcoholic drink?
- D. What foods did you eat at your last meal?
Correct Answer: C
Rationale: Recent alcohol consumption can exacerbate liver failure and affect treatment decisions, making it the priority question. Duration of drinking, advance directives, and diet are secondary.
Which diagnostic data should be reported to the health-care provider (HCP) immediately?
- A. The ABG result of pH 7.11, PaCO2 45, HCO3 20, and PaO2 98 for a client diagnosed with type 1 diabetes.
- B. Sodium 137 mEq/L, potassium 4 mEq/L, glucose 120 mg/dL for a client diagnosed with gastroenteritis.
- C. Hemoglobin 9.4 g/dL and hematocrit 29% for a client who received a blood transfusion on the previous shift.
- D. A pulse oximetry reading of 93% for a client diagnosed with chronic obstructive pulmonary disease (COPD).
Correct Answer: A
Rationale: A pH of 7.11 indicates severe acidosis (likely DKA in type 1 diabetes), requiring immediate HCP notification. Normal electrolytes, post-transfusion anemia, and COPD oximetry are less urgent.