Nokea
The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?
- A. Asterixis
- B. Hypertension
- C. Kussmaul respirations
- D. Lethargy
Correct Answer: A
Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.
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Which symptoms is the client who overdosed on barbiturates most likely to exhibit?
- A. Bradypnea and bradycardia
- B. Hyperthermia and drowsiness
- C. Hyperreflexia and slurred speech
- D. Tachycardia and psychosis
Correct Answer: A
Rationale: The correct answer is bradypnea and bradycardia. Barbiturates are central nervous system (CNS) depressants, which will slow down the respiratory rate (bradypnea) and heart rate (bradycardia). Choice B, hyperthermia and drowsiness, is incorrect as barbiturate overdose typically does not cause hyperthermia but rather hypothermia. Hyperreflexia and slurred speech (Choice C) are more indicative of stimulant overdoses rather than CNS depressants like barbiturates. Tachycardia and psychosis (Choice D) are also not typically seen in barbiturate overdose, as these drugs tend to depress the CNS rather than cause symptoms of increased heart rate or psychosis.
What is most important for the healthcare professional to do prior to initiating peritoneal dialysis?
- A. Aspirate to check placement
- B. Ensure the client voids
- C. Irrigate the catheter to maintain patency
- D. Warm the fluids
Correct Answer: D
Rationale: The correct answer is to warm the fluids. Warming the dialysis fluids is crucial before initiating peritoneal dialysis to prevent abdominal discomfort and promote vasodilation, which helps in achieving good exchange in the peritoneum. Aspirating to check placement (Choice A) is not typically necessary before initiating peritoneal dialysis. Ensuring the client voids (Choice B) is not directly related to the procedure of peritoneal dialysis. Irrigating the catheter to maintain patency (Choice C) is usually done as part of routine care but is not specifically required prior to initiating peritoneal dialysis. Therefore, the most important action to take before starting peritoneal dialysis is to warm the fluids.
Which of the following food selections would need to be removed from a tray for a client recovering from thyroidectomy?
- A. Fresh apple
- B. V8 juice
- C. Mustard greens
- D. Ice cream
Correct Answer: A
Rationale: The correct answer is a fresh apple. After a thyroidectomy, it is important to avoid hard and crunchy foods like apples due to the proximity of the esophagus to the surgical site. Apples can be difficult to chew and swallow, posing a risk of injury or discomfort to the patient. V8 juice, mustard greens, and ice cream are softer options that would be more suitable for a client recovering from thyroidectomy.
A client has been receiving cyanocobalamin (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?
- A. Neutrophil count of 60%
- B. Basophil count of 0.5%
- C. Monocyte count of 2%
- D. Reticulocyte count of 1%
Correct Answer: D
Rationale: Cyanocobalamin is a B12 medication used for pernicious anemia. A reticulocyte count of 1% indicates the desired effect of the medication, as reticulocytes are immature red blood cells that increase in response to B12 therapy, improving anemia. Neutrophils, basophils, and monocytes are white blood cells and are not directly influenced by B12 injections, making them incorrect choices.
Which electrolyte imbalance would be the nurse's priority concern in the burn client?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hypoalbuminemia
- D. Hypermagnesemia
Correct Answer: B
Rationale: The correct answer is hyperkalemia. In a burn client, the nurse's priority concern is hyperkalemia due to cell lysis, which releases potassium into the bloodstream. This can lead to dangerous levels of potassium in the blood. Hypernatremia (Choice A) is less likely in burn clients. Hypoalbuminemia (Choice C) can occur but is not the priority in the immediate management of a burn client. Hypermagnesemia (Choice D) is not typically associated with burn injuries.