Nokea
The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?
- A. Increase the amount of sodium in the diet.
- B. Limit the amount of fluids consumed.
- C. Encourage frequent ambulation.
- D. Administer magnesium antacids.
Correct Answer: B
Rationale: The correct answer is B: Limit the amount of fluids consumed. In cirrhosis with ascites and excess fluid volume, limiting fluid intake helps reduce fluid overload and prevent further accumulation of fluid in the body. Excess fluid can worsen ascites, leading to complications like respiratory distress and electrolyte imbalances. Increasing sodium intake (A) would worsen fluid retention. Encouraging ambulation (C) is important but not directly related to managing ascites. Administering magnesium antacids (D) is not necessary for addressing fluid volume excess.
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A client with a history of gastric ulcer suddenly complains of a sharp-severe pain in the mid epigastric area, which then spreads over the entire abdomen. The client's abdomen is rigid and board-like to palpation, and the client obtains most comfort from lying in the knee-chest position. The nurse calls the physician immediately suspecting that the client is experiencing which of the following complications of peptic ulcer disease?
- A. Perforation
- B. Obstruction
- C. Hemorrhage
- D. Intractability
Correct Answer: A
Rationale: The correct answer is A: Perforation. The sudden onset of sharp-severe pain, rigidity, and board-like abdomen are classic signs of a perforated gastric ulcer. The spreading pain and relief in the knee-chest position indicate free air in the peritoneal cavity. Perforation is a serious complication requiring immediate medical attention to prevent peritonitis and sepsis.
Choice B: Obstruction is incorrect because it typically presents with a gradual onset of pain, bloating, vomiting, and inability to pass stool or gas.
Choice C: Hemorrhage is incorrect as it usually presents with symptoms like hematemesis, melena, and signs of blood loss such as hypotension and tachycardia.
Choice D: Intractability is incorrect because it refers to the condition being difficult to manage or cure, which is not the acute presentation described in the question.
Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:
- A. verbalize absence of epigastric pain.
- B. accept the need to inject himself with vitamin B12 for the rest of his life.
- C. understand the need to increase his exercise activity.
- D. eliminate stress from his life.
Correct Answer: A
Rationale: The correct answer is A: verbalize absence of epigastric pain. This outcome is most appropriate as it directly relates to the client's condition of peptic ulcer disease. Verbalizing the absence of epigastric pain indicates that the client's ulcer is healing and symptoms are improving. It is a measurable and specific goal that reflects the client's progress in managing the disease.
Choice B is incorrect as vitamin B12 injections are not typically necessary for peptic ulcer disease. Choice C is incorrect as exercise may not directly impact the ulcer and may even exacerbate symptoms. Choice D is incorrect as eliminating stress completely is unrealistic and may not directly impact the ulcer.
Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?
- A. Administering pain medication.
- B. Completing the admission history.
- C. Maintaining hydration.
- D. Teaching about planned diagnostic tests.
Correct Answer: A
Rationale: The correct answer is A: Administering pain medication. Immediate pain relief is crucial in managing cholecystitis symptoms and improving the client's comfort. Pain can lead to increased stress, anxiety, and physiological responses that can worsen the condition. Administering pain medication promptly can help alleviate these symptoms and allow the client to rest. Completing the admission history (B) is important but can be done after addressing the urgent pain and discomfort. Maintaining hydration (C) is also essential but may not be the highest priority compared to pain relief. Teaching about planned diagnostic tests (D) is important for the client's understanding but can be deferred until the pain and discomfort are managed effectively.
The nurse provides discharge instructions to a patient with hepatitis B. Which of the following statements, if made by the patient, would indicate the need for further instruction?
- A. I can never donate blood.
- B. I can never have unprotected sex.
- C. I cannot share needles.
- D. I should avoid drugs and alcohol.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): The patient should avoid drugs and alcohol to prevent further damage to the liver affected by hepatitis B. Substance abuse can exacerbate liver disease. This statement indicates understanding of the importance of liver health.
Summary of Other Choices:
A: This statement is correct because individuals with hepatitis B should not donate blood to prevent transmission.
B: This statement is correct because unprotected sex can transmit hepatitis B to sexual partners.
C: This statement is correct because sharing needles can spread hepatitis B through blood-to-blood contact.
The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the client's plan of care?
- A. Encourage regular use of antidiarrheal medications.
- B. Incorporate frequent rest periods into the client's schedule.
- C. Have the client maintain a high-fiber diet.
- D. Wear a gown when providing direct client care.
Correct Answer: B
Rationale: The correct answer is B: Incorporate frequent rest periods into the client's schedule. Rest periods are essential for managing ulcerative colitis exacerbations as they help reduce stress on the digestive system. Antidiarrheal medications (A) may worsen the condition by masking symptoms and delaying appropriate treatment. High-fiber diets (C) can aggravate symptoms in some individuals with ulcerative colitis. Wearing a gown (D) is unrelated to managing ulcerative colitis exacerbations.