Nokea
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
- A. Aldosterone.
- B. Creatinine.
- C. Potassium.
- D. Protein.
Correct Answer: C
Rationale: Hypokalemia (C) increases ammonia production, precipitating hepatic encephalopathy. Aldosterone (A), creatinine (B), and protein (D) are not directly linked to this condition's onset.
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A client who has had a total laryngectomy appears withdrawn and depressed. He keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing intervention would have the threshold to be removed.
- A. Discussing his behavior with his wife to determine the cause.
- B. Exploring his future plans.
- C. Respecting his need for privacy.
- D. Encouraging him to express his feelings nonverbally and in writing.
Correct Answer: D
Rationale: Encouraging nonverbal or written expression allows the client to process emotions despite speech loss, addressing psychological needs. Discussing with his wife breaches confidentiality. Exploring future plans may be premature. Respecting privacy may reinforce withdrawal.
Bethanechol (Urecholine) has been ordered for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which of the following adverse effects?
- A. Constipation.
- B. Urinary urgency.
- C. Hypertension.
- D. Dry oral mucosa.
Correct Answer: B
Rationale: Bethanechol, a cholinergic agent, can cause urinary urgency as an adverse effect due to its stimulation of smooth muscle contraction, including in the bladder.
When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following?
- A. Herpes zoster infections.
- B. Discolored teeth.
- C. Hemorrhage.
- D. Hypercellular immunity.
Correct Answer: A
Rationale: Hodgkin's disease impairs immune function, increasing the risk of infections like herpes zoster (shingles). Discolored teeth, hemorrhage, and hypercellular immunity are not typical findings.
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
- A. Helping the client maintain a positive selfconcept.
- B. Promoting hygiene.
- C. Everything infection.
- D. Educating the client regarding care of the skin grafts.
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.
Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled?
- A. Muscle spasms.
- B. Nausea.
- C. Shivering.
- D. Dry mouth.
Correct Answer: B
Rationale: Ondansetron is an antiemetic, effective when nausea is controlled.