Nokea
The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for the greatest concern?
- A. I have a tight sensation in my lower leg when I forget to put my feet up.
- B. I can't button my pants anymore because my belly is so swollen.
- C. I'm very constipated and have been straining during bowel movements.
- D. When I sleep, I have to sit in a recliner so that I can breathe more easily.
Correct Answer: B
Rationale: This indicates new or worsening ascites, a serious complication of portal hypertension requiring evaluation.
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A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?
- A. The client's bladder becomes distended.
- B. The client states having a severe headache.
- C. The client states having nasal congestion.
- D. The client's blood pressure becomes elevated.
Correct Answer: A
Rationale: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure.
A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).
- A. Tachycardia
- B. Rebound tenderness
- C. Rigid abdomen
- D. Elevated blood pressure
Correct Answer: A,B,C
Rationale: These are classic signs of perforation and peritonitis: tachycardia from pain/stress, rebound tenderness and rigidity from peritoneal irritation.
A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).
- A. Profuse vomiting with fecal odor
- B. Epigastric abdominal distention
- C. Intermittent abdominal cramping
- D. Ribbon-like stools or diarrhea
- E. Metabolic acidosis
- F. Severe fluid and electrolyte imbalance
Correct Answer: A,B,C,D,E,F
Rationale: All are potential findings in LBO due to mechanical obstruction, bacterial overgrowth, and fluid shifts.
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
A client is being admitted to the emergency department with a possible dissecting abdominal aortic aneurysm. Which of the following clinical manifestations are not signs and symptoms of hypovolemic shock?
- A. Nausea and faintness
- B. Neurologic deficits and apprehension
- C. Hypertension and tachypnea
- D. Diaphoresis and oliguria
Correct Answer: C
Rationale: Hypertension is not typical in hypovolemic shock (hypotension is expected).