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The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) best reflects the client's symptoms of tiring rapidly due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported.
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A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
- A. Incorporate physical exercise as tolerated into the daily routine.
- B. Monitor peak flow numbers after meals and at bedtime.
- C. Eliminate stressors in the work and home environment.
- D. Use sedatives to ensure uninterrupted sleep at night.
Correct Answer: A
Rationale: Regular exercise, as tolerated, improves lung function and overall health in asthma. Peak flow monitoring is typically done morning and evening. Eliminating all stressors is unrealistic. Sedatives may depress respiration and are not recommended.
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
A client states, 'I don't want any more tests. Who cares what kind of leukemia I have? I just want to be treated now.' Which is the nurse's best response?
- A. I'm sure you are frustrated and want to be well now.'
- B. Your treatment can be more effective if it is based on more specific information about your disease.'
- C. Now, you know the tests are necessary and that you are just upset right now.'
- D. I understand how you feel.'
Correct Answer: B
Rationale: The nurse should explain that specific tests help tailor treatment to the type of leukemia, improving effectiveness. This addresses the client's desire for treatment while emphasizing the importance of diagnostic clarity. The other responses are empathetic but do not provide a rationale for testing.
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler's.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The high lithotomy position, used for procedures like vaginal hysterectomy, involves legs elevated in stirrups, as likely depicted in the figure, and should be documented accurately.