Nokea
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.
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The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.
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 at the scene of a knife fight is caring for a young man who has a knife in his abdomen. Which action should the nurse implement?
- A. Stabilize the knife.
- B. Remove the knife gently.
- C. Turn the client on the side.
- D. Apply pressure to the insertion site.
Correct Answer: A
Rationale: Stabilizing the knife prevents further internal damage until surgical intervention. Removing it, turning the client, or applying pressure risks worsening bleeding.
The nurse is caring for the client who had a vertical banded gastroplasty. The nurse teaches that nausea can occur after this surgery from which situation?
- A. The stomach pouch becomes overfilled.
- B. The lower half of the stomach becomes spastic.
- C. The duodenum incision becomes inflamed.
- D. The dumping syndrome from a high-protein meal.
Correct Answer: A
Rationale: A. A small pouch (15—20 mL capacity) is constructed in the upper part of the stomach during vertical banded gastroplasty. Overfilling of this pouch stimulates afferent nerve fibers, which relay information to the chemoreceptor trigger zone in the brain, causing nausea. B. The function of the lower half of the stomach is not affected with a vertical banded gastroplasty. C. The duodenum is not incised during a vertical banded gastroplasty. D. Dumping syndrome is more likely to occur from a meal high in simple carbohydrates, not protein.
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.