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The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician?
- A. Sluggish bowel sounds
- B. Pain and tenderness at the umbilicus
- C. Passage of small amount of liquid stool
- D. Increasing abdominal girth
Correct Answer: D
Rationale: Increasing abdominal girth post-hemicolectomy may indicate complications like bleeding, ileus, or perforation, requiring immediate physician notification. Sluggish bowel sounds, umbilical pain, and liquid stool are expected early post-op.
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A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
- A. Scarf sign
- B. Harlequin sign
- C. Cullen's sign
- D. Trendelenburg sign
Correct Answer: D
Rationale: Trendelenburg sign, where the pelvis tilts downward on the unaffected side when standing on the affected leg, is associated with congenital hip dysplasia due to weak hip abductors. The other signs are unrelated.
A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:
- A. Assess level of consciousness
- B. Assess suicide potential
- C. Observe for sedation and hypotension
- D. Orient to her room and unit rules
Correct Answer: B
Rationale: Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk.
The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?
- A. Report unexplained muscle weakness to the physician
- B. Allow six months for the drug to take effect
- C. Take the medication with fruit juice
- D. Report difficulty sleeping
Correct Answer: A
Rationale: Rosuvastatin a statin can cause myopathy or rhabdomyolysis. Unexplained muscle weakness is a serious side effect requiring immediate reporting to prevent complications. The other options are not specific to rosuvastatin therapy.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
- A. Sodium
- B. Potassium
- C. Protein
- D. Fat
Correct Answer: C
Rationale: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.
A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:
- A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms.
- B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue.
- C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend.
- D. Respect the client's family's wishes.
Correct Answer: D
Rationale: It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel. Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. The nurse should leave the room and allow the family privacy in their grief. The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs.