Nokea
The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care?
- A. Assess the abdomen for a tympanic wave.
- B. Monitor the client's blood pressure.
- C. Percuss the liver for size and location.
- D. Weigh the client twice each week.
Correct Answer: B
Rationale: Monitoring blood pressure detects complications of portal hypertension, like variceal bleeding. Tympanic wave is incorrect, liver percussion is less urgent, and weight checks are secondary.
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The nurse caring for a client diagnosed with GERD writes the client problem of 'behavior modification.' Which intervention should be included for this problem?
- A. Teach the client to sleep with a foam wedge under the head.
- B. Encourage the client to decrease the amount of smoking.
- C. Instruct the client to take over-the-counter medication for relief of pain.
- D. Discuss the need to attend Alcoholics Anonymous to quit drinking.
Correct Answer: A
Rationale: Sleeping with a foam wedge elevates the head, reducing reflux by preventing stomach acid from flowing into the esophagus during sleep, a key behavioral modification for GERD. Smoking cessation is beneficial but less specific to immediate symptom relief, and the other options are not directly related to behavior modification for GERD.
Following a hemorrhoidectomy, the nurse assesses the client's voiding. What is the reason for this concern?
- A. The client has been NPO before and during surgery.
- B. Urinary retention is frequently seen after a hemorrhoidectomy.
- C. The client has a long history of hemorrhoids, making her prone to voiding problems.
- D. The client had several pregnancies, which can make voiding difficult.
Correct Answer: B
Rationale: Urinary retention is common post-hemorrhoidectomy due to pain and swelling affecting pelvic nerves.
The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis?
- A. Eat a high-fiber diet.
- B. Increase fluid intake.
- C. Elevate the HOB after eating.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: A,B,D
Rationale: High-fiber diet, increased fluids, and regular exercise (e.g., walking) prevent constipation and reduce pressure in diverticula, lowering exacerbation risk. Elevating the HOB and antacids are unrelated to diverticulosis prevention.
The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving?
- A. The client is using more pain medication on a daily basis.
- B. The client's nasogastric tube is draining coffee-ground material.
- C. The client has a decrease in temperature and a soft abdomen.
- D. The client has had two (2) soft-formed bowel movements.
Correct Answer: C
Rationale: A decrease in temperature and a soft abdomen indicate resolving infection and inflammation in peritonitis. Increased pain medication, coffee-ground drainage, and bowel movements are not improvement signs.
The client's temperature rises to 38°C (100.4°F) on the first postoperative day following abdominal surgery. The nurse interprets this to be:
- A. indicative of a wound infection.
- B. a normal physiological response to the trauma of surgery.
- C. suggestive of a urinary tract infection.
- D. an indication of overhydration.
Correct Answer: B
Rationale: A slight temperature elevation (100.4°F) on the first postoperative day is a normal response to surgical trauma.