Nokea
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct Answer: C
Rationale: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.
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The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply.
- A. Dodgeball
- B. Reading a book
- C. Stationary bicycling
- D. Swimming
- E. Yoga
Correct Answer: C,D,E
Rationale: Stationary bicycling, swimming, and yoga are low-impact, joint-friendly activities for JIA. Dodgeball risks joint stress, and reading, while safe, is not a physical activity.
The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?
- A. Baked salmon with rice, steamed vegetables, and dinner roll
- B. Breaded pork chops, corn on the cob, and steamed snow peas
- C. Grilled chicken, green beans, and mashed potatoes
- D. Spaghetti with Italian tomato sauce and meatballs
Correct Answer: C
Rationale: Grilled chicken, green beans, and mashed potatoes are gluten-free, suitable for celiac disease. Dinner rolls, breaded pork chops, and spaghetti contain gluten, which must be avoided.
The nurse is collecting data from a client with Bell’s palsy. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. Inability to smile symmetrically
- B. Frequent blinking of the affected eye
- C. Shock-like pain in the lips and gums
- D. Loss of forehead and brow movements
- E. Decreased lacrimation on the affected side
Correct Answer: A,D,E
Rationale: Bell’s palsy causes unilateral facial weakness, leading to asymmetrical smiling, loss of forehead/brow movement, and reduced lacrimation. Frequent blinking is unlikely due to impaired muscle control, and shock-like pain is typical of trigeminal neuralgia.
An adult client who had a cervical laminectomy is returned to her room on the nursing care unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. The nurse should position the client in which of the following positions?
- A. Supine
- B. Semi-reclining
- C. Side-lying
- D. Prone
Correct Answer: C
Rationale: Side-lying position promotes comfort and maintains spinal alignment post-cervical laminectomy, reducing strain on the surgical site. Supine or prone positions may increase pressure on the neck, and semi-reclining is less optimal for spinal stability.
An adult is admitted for surgery today. Immediately after administering the preoperative medications of meperidine and atropine, the nurse notes that the operative permit has not been signed. Which action should the nurse take?
- A. Have the client sign the operative permit immediately before the medications take effect
- B. Have the client's next of kin sign the permission form
- C. Ask the client if he/she is willing to undergo surgery, sign the form for the client, and indicate the nurse's name as witness to the client's verbal consent
- D. Report it to the physician so the surgery can be delayed until the client can legally sign a consent form
Correct Answer: D
Rationale: Preoperative medications like meperidine impair judgment, making consent invalid post-administration. Reporting to the physician to delay surgery ensures legal and ethical consent.