Nokea
The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What should the nurse do to appropriately test for asterixis?
- A. Examine the client's handwriting movements.
- B. Check the stool for clay-colored pigmentation.
- C. Ask the client to extend the wrist and the fingers.
- D. Check the serum bilirubin and liver enzyme levels.
Correct Answer: C
Rationale: Asterixis, or liver flap, is a rapid, nonrhythmic tremor in hepatic encephalopathy, tested by having the client extend the wrist and fingers. Handwriting is nonspecific, stool color is unrelated, and lab tests do not assess asterixis directly.
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The nurse has given instructions to a client who is returning home after an arthroscopy of the knee. The nurse determines that the client understands the home care instructions if the client states the need to follow which instruction?
- A. Resume strenuous exercise the following day.
- B. Stay off the leg entirely for the rest of the day.
- C. Refrain from eating food for the remainder of the day.
- D. Report fever or site inflammation to the primary health care provider.
Correct Answer: D
Rationale: After arthroscopy, signs/symptoms of infection should be reported to the primary health care provider. The client is instructed to avoid strenuous exercise for at least a few days; however, the client can usually walk carefully on the leg after sensation has returned. The client may resume the usual diet.
The nurse is reviewing the medication history for a 24-year-old client in the fertility clinic. Which medication does the nurse understand to be a Category X medication in pregnancy?
- A. metformin
- B. amoxicillin
- C. gabapentin
- D. simvastatin
Correct Answer: D
Rationale: Simvastatin is Category X, contraindicated in pregnancy due to fetal harm. Others are safer (Categories B or C).
The nurse is evaluating a hypertensive client's understanding of dietary modifications to control the disease process. The nurse determines that the client's understanding is satisfactory if the client made which meal selections?
- A. Corned beef, fresh carrots, boiled potato
- B. Hot dog on a bun, sauerkraut, baked beans
- C. Turkey, baked potato, salad with oil and vinegar
- D. Scallops, French fries, salad with bleu cheese dressing
Correct Answer: C
Rationale: Hypertensive clients should avoid high-sodium foods like corned beef, hot dogs, sauerkraut, scallops, French fries, and bleu cheese dressing. Turkey, baked potato, and salad with oil and vinegar are low in sodium, indicating correct dietary understanding.
The clinic nurse provides instructions to a client who will begin taking oral contraceptives. Which statement by the client indicates the need for further teaching?
- A. I will take one pill daily at the same time every day.
- B. If I miss a pill, I must take it as soon as I remember.
- C. I will not need to use an additional birth control method after I start these pills.
- D. If I miss two pills, I will take them both as soon as I remember, and then two pills the next day.
Correct Answer: C
Rationale: The client must use a second birth control method during the first pill cycle of oral contraceptives to ensure protection against pregnancy. Taking the pill at the same time daily, taking a missed pill as soon as remembered, and taking two missed pills as soon as remembered with two the next day are correct actions.
The nurse instructs a client who is hospitalized and on a low-fat diet. Which menu does the nurse provide for the client?
- A. Shrimp, avocado, and tomato salad
- B. Calf's liver, potato salad, and sherbet
- C. Lean steak, mashed potatoes, and gravy
- D. Turkey breast, boiled rice, and strawberries
Correct Answer: D
Rationale: Turkey breast without the skin, boiled rice, and strawberries offer the client nourishing foods that are low in fat. Some sources of fat include meats, avocado, salad dressing, mayonnaise, butter, cheese, and bacon. The remaining options contain high-fat foods.