Nokea
The nurse is caring for a client with a history of cirrhosis.
- A. Which assessment finding is most concerning for a client with cirrhosis?
- B. Ascites and peripheral edema.
- C. Jaundice and pruritus.
- D. Asterixis and confusion.
- E. Dark, tarry stools.
Correct Answer: C
Rationale: Asterixis and confusion indicate hepatic encephalopathy, a life-threatening complication of cirrhosis due to ammonia buildup, requiring immediate intervention. Ascites, jaundice, and melena are concerning but less acute.
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An unaccompanied client who is six months pregnant is admitted to the nursing unit with vaginal bleeding.
Which of the following comments, if made by the client, would indicate a need for the nurse to assess the adequacy of the client's emotional support?
- A. My husband will be so angry with me if I lose this baby.
- B. I'm afraid I am going to lose my baby.
- C. I can't stay here. I don't have any insurance.
- D. I feel so guilty. I didn't want to get pregnant.
Correct Answer: A
Rationale: Strategy: Think about what the words mean. (1) correct-client's concern about her husband's feelings indicates that he may not be able to support her emotionally at this time (2) reflects a reality-based concern (3) indicates an economic concern (4) indicates client needs to talk about her current feelings; does not give any indication of level of emotional support
A 7-year-old daughter weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year.
Which of the following responses by the nurse is BEST?
- A. Your daughter's height and weight are within normal limits.'
- B. Your daughter's height is normal, but she needs to gain some weight.'
- C. Your daughter's height is normal, but she needs to lose some weight.'
- D. Your daughter's weight is normal, but she is shorter than normal.'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates that you will have to discriminate between answers. The topic of the question is unstated. Read answer choice to obtain clues. (1) correct-between ages 6-12 grows about 2 in (5 cm)/year and gains 4.5-6.5 lb (2-3 kg)/year, at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 in (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits
An infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis.
Which of the following should be the nursing priority for an infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis?
- A. Encourage intake of oral fluids to prevent dehydration.
- B. Restrain the child appropriately to maintain the integrity of the IV site.
- C. Place the child on droplet precautions.
- D. Encourage the parents to hold and rock the infant to promote comfort.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) fluid requirements are determined by child's hydration status; fluids are usually limited to prevent cerebral edema (2) not a priority (3) correct-to prevent spread of infection, child is placed on droplet precautions for at least 24 hours after implementation of antibiotic therapy (4) would cause discomfort to infant's head
A 63-year-old woman is taking digitalis, baby aspirin, potassium (K-Dur), and furosemide (Lasix) daily. She complains of multiple symptoms, which include muscle cramps and facial tics. Physical exam reveals positive Chvostek's and Trousseau's signs, hypotension, and confusion. The nurse suspects she has hypomagnesemia. What else should the nurse expect?
- A. Laboratory tests to reveal high serum calcium and potassium levels
- B. Laboratory tests to reveal low serum calcium and potassium levels
- C. Altered acid-base balance, which requires administration of NaHCO3 intravenously in addition to treatment for hypomagnesemia
- D. An order for an ECG to monitor brain function
Correct Answer: B
Rationale: Hypomagnesemia often accompanies low calcium and potassium, as seen with furosemide use, explaining symptoms like cramps and tetany.
A 14-year-old is going home with a permanent tracheostomy. Which comment by the child's mother indicates to the nurse that the parent needs more instruction?
- A. I need to ask the doctor how many times a day I can suction my child.'
- B. I will suction if my child cannot effectively cough up sputum.'
- C. I know my child will not need the same amount of suctioning every day.'
- D. I know I should only suction my child if it is really necessary.'
Correct Answer: A
Rationale: Asking for a fixed suctioning schedule suggests misunderstanding, as suctioning is PRN based on need, indicating a need for further instruction.