Nokea
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
- A. Peripheral edema.
- B. Ascites.
- C. Anorexia.
- D. Jaundice.
Correct Answer: D
Rationale: Jaundice (D) is a common early sign of cirrhosis due to impaired bilirubin metabolism. Peripheral edema (A) and ascites (B) occur later. Anorexia (C) is less specific.
You may also like to solve these questions
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.
Which teaching point is essential for a client with a seizure disorder?
- A. Avoid all physical activity.
- B. Take medications as prescribed.
- C. Limit sleep to 6 hours nightly.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Taking medications as prescribed is essential to control seizures and prevent recurrence.
When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply.
- A. Epigastric pain at night.
- B. Relief of epigastric pain after eating.
- C. Vomiting.
- D. Weight loss.
- E. Melena.
Correct Answer: A,C,E
Rationale: Gastric ulcers commonly cause epigastric pain at night, vomiting, and melena (dark, tarry stools) due to bleeding. Relief of pain after eating is more typical of duodenal ulcers, and weight loss is less common with gastric ulcers.
The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should:
- A. Begin chest compressions.
- B. Call the rapid response team.
- C. Remove the family from the room.
- D. Ventilate the client with an ambu bag.
Correct Answer: B
Rationale: Unresponsiveness, hypotension, and low SpO2 indicate a critical condition. Calling the rapid response team ensures immediate multidisciplinary intervention.
A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care?
- A. Relieving pain.
- B. Preserving joint function.
- C. Maintaining usual ways of accomplishing tasks.
- D. Preventing joint deformity.
Correct Answer: C
Rationale: During the acute phase, relieving pain, preserving joint function, and preventing deformity are critical to manage inflammation and prevent long-term damage. Maintaining usual ways of accomplishing tasks is less urgent.