Nokea
The nurse is caring for an elderly client diagnosed with acute gastritis. Which client problem is priority for this client?
- A. Fluid volume deficit.
- B. Altered nutrition: less than body requirements.
- C. Impaired tissue perfusion.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly clients with acute gastritis due to vomiting/diarrhea, risking dehydration. Nutrition, perfusion, and comfort are secondary.
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The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.
The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent health-care associated infection (HAl) spread to other clients?
- A. Wash hands with Betadine for two (2) minutes after giving care.
- B. Wear nonsterile gloves when handling GI excretions.
- C. Clean the perianal area with soap and water after each stool.
- D. Flush the commode twice when disposing of stool.
Correct Answer: C
Rationale: Cleaning the perianal area with soap and water after each stool reduces the risk of Clostridium difficile spore transmission, which is critical for preventing healthcare-associated infections. Betadine is not standard, gloves are insufficient alone, and flushing twice is not evidence-based.
Which assessment data supports the client's diagnosis of gastric ulcer to the nurse?
- A. Presence of blood in the client's stool for the past month.
- B. Reports of a burning sensation moving like a wave.
- C. Sharp pain in the upper abdomen after eating a heavy meal.
- D. Complaints of epigastric pain 30 to 60 minutes after ingesting food.
Correct Answer: D
Rationale: Gastric ulcers typically cause epigastric pain 30–60 minutes after eating due to acid irritation of the ulcerated mucosa. Blood in stool is more indicative of lower GI issues, a wave-like sensation is vague, and sharp pain after heavy meals is less specific.
The nurse is caring for the client diagnosed with hepatic encephalopathy. Which sign and symptom indicate the disease is progressing?
- A. The client has a decrease in serum ammonia level.
- B. The client is not able to circle choices on the menu.
- C. The client is able to take deep breaths as directed.
- D. The client is able to eat previously restricted food items.
Correct Answer: B
Rationale: Inability to circle menu choices indicates worsening cognitive function, a sign of progressing hepatic encephalopathy. Decreased ammonia, following directions, and eating are positive or unrelated.
The nurse is caring for the client with hepatic encephalopathy who is receiving lactulose. Which finding should the nurse expect after the administration of this medication?
- A. An increase in body temperature
- B. Neurological changes, such as confusion
- C. A change in urine specific gravity
- D. A decrease in oral fluid intake
Correct Answer: B
Rationale: A. The client’s temperature will not be affected. B. Elevated serum ammonia levels may cause neurological changes, such as confusion. C. The client’s urine specific gravity will not be affected. D. Oral fluid intake should be encouraged if tolerated by the client.