Nokea
The nurse is caring for a client with cirrhosis of the liver. Which clinical finding is most concerning?
- A. Jaundice.
- B. Ascites.
- C. Spider angiomas.
- D. Asterixis.
Correct Answer: D
Rationale: The correct answer is D, Asterixis. Asterixis, also known as liver flap, is a sign of hepatic encephalopathy, a severe complication of liver disease that necessitates immediate attention. While jaundice (choice A), ascites (choice B), and spider angiomas (choice C) are common clinical findings in cirrhosis, asterixis is the most concerning due to its association with hepatic encephalopathy, which can lead to altered mental status and even coma. Jaundice, ascites, and spider angiomas are also important signs in cirrhosis, but asterixis indicates a more critical condition requiring urgent intervention.
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What is the primary purpose of a chest tube in a client's care?
- A. To drain air and fluid from the pleural space
- B. To prevent infection in the thoracic cavity
- C. To assist with lung expansion
- D. To monitor intrathoracic pressure
Correct Answer: A
Rationale: The correct answer is A: To drain air and fluid from the pleural space. A chest tube is primarily used to remove accumulated air or fluid in the pleural space, preventing lung collapse or compromise of lung function. This intervention aims to re-expand the lung and enhance respiratory function. Choice B is incorrect because preventing infection is not the primary purpose of a chest tube. Choice C is incorrect as lung expansion is a result of draining the pleural space, not the primary goal. Choice D is incorrect as monitoring intrathoracic pressure is not the main objective of a chest tube insertion.
A client who has just been diagnosed with tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?
- A. Avoid close contact with others until treatment is complete
- B. Take all prescribed medications as directed
- C. Schedule a follow-up appointment with the healthcare provider
- D. Wear a mask when in public places
Correct Answer: B
Rationale: The correct answer is B: 'Take all prescribed medications as directed.' This instruction is the most important because adherence to the prescribed medication regimen is crucial in treating tuberculosis effectively and preventing the development of drug-resistant TB. While choice A is important for infection control, ensuring treatment adherence through proper medication intake takes precedence. Choice C is also essential for monitoring progress but is not as critical as ensuring medication compliance. Choice D is relevant for preventing transmission but is not as crucial as ensuring proper treatment by taking medications as directed.
A client with a diagnosis of osteoporosis is prescribed alendronate (Fosamax). What is the most important instruction the nurse should provide?
- A. Take the medication in the morning on an empty stomach.
- B. Take the medication at bedtime.
- C. Remain upright for at least 30 minutes after taking the medication.
- D. Take the medication with a full glass of water.
Correct Answer: D
Rationale: The most important instruction the nurse should provide to a client prescribed alendronate (Fosamax) for osteoporosis is to take the medication with a full glass of water. This is crucial to help prevent esophageal irritation. Option A is correct as alendronate should be taken in the morning on an empty stomach. Option C is incorrect because the client should remain upright for at least 30 minutes after taking the medication, not lie down. Option B is incorrect and a duplicate of Option A.
A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?
- A. Administer antibiotics as prescribed
- B. Perform chest physiotherapy
- C. Encourage increased fluid intake
- D. Provide humidified oxygen
Correct Answer: C
Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.
A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)
- A. Portal hypertension.
- B. Sodium and water retention.
- C. Decreased serum albumin.
- D. All of the above
Correct Answer: D
Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.