Nokea
The nurse is assisting a client diagnosed with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree item?
- A. Tomato soup
- B. Fresh fruit plate
- C. Vegetable lasagna
- D. Ground beef patty
Correct Answer: D
Rationale: Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, milk, peanut butter, and gelatin. The food items in options 1, 2, and 3 are acceptable to eat.
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The nurse monitors the client taking amitriptyline for which common side effect?
- A. Diarrhea
- B. Drowsiness
- C. Hypertension
- D. Increased salivation
Correct Answer: B
Rationale: Common side effects of amitriptyline (a tricyclic antidepressant) include the central nervous system effects of drowsiness, fatigue, lethargy, and sedation. Other common side effects include dry mouth or eyes, blurred vision, hypotension, and constipation. The nurse monitors the client for these side effects.
The nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? Select all that apply.
- A. Headache
- B. Tachycardia
- C. Hypertension
- D. Apprehension
- E. Distended neck veins
- F. A sense of impending doom
Correct Answer: A,B,D,F
Rationale: Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood containing antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. These complexes destroy the transfused cells and start inflammatory responses in the client's blood vessel walls and organs. The reaction may include fever and chills or may be life-threatening with disseminated intravascular coagulation and circulatory collapse. Other manifestations include headache, tachycardia, apprehension, a sense of impending doom, chest pain, low back pain, tachypnea, hypotension, and hemoglobinuria. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload.
A multidisciplinary team working with the spouse of a home care client who has end-stage liver failure is teaching the spouse about pain management. Which statement by the spouse indicates the need for further teaching?
- A. My husband can use breathing exercises to control pain.
- B. I will help prevent constipation with increased fluids.
- C. If the pain increases, I will report it to the nurse promptly.
- D. The medication causes very deep sleep that my husband needs.
Correct Answer: D
Rationale: In the client with liver disease, the ability to metabolize medication is affected. A decreased level of consciousness is a potential clinical indicator of medication overdose, as well as fluid, electrolyte, and oxygenation deficiencies; thus, the nurse teaches the client's spouse about the differences between sleep related to pain relief and a deteriorating change in neurological status. Options 1, 2, and 3 all indicate an understanding of suitable steps to be taken in pain management.
When tranylcypromine is prescribed for a client, which food items should the nurse instruct the client to avoid? Select all that apply.
- A. Figs
- B. Apples
- C. Bananas
- D. Broccoli
- E. Sauerkraut
- F. Baked chicken
Correct Answer: A,C,E
Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Foods that contain tyramine need to be avoided because of the risk of hypertensive crisis associated with use of this medication. Foods to avoid include figs; bananas; sauerkraut; avocados; soybeans; meats or fish that are fermented, smoked, or otherwise aged; some cheeses; yeast extract; and some beers and wine.
A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse should ask the client about a recent history of which event?
- A. Bleeding ulcer
- B. Myocardial infarction
- C. Deep vein thrombosis
- D. Streptococcal infection
Correct Answer: D
Rationale: The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, myocardial infarction, and deep vein thrombosis are not precipitating causes.