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The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area?
- A. Duodenum
- B. Gastric pylorus
- C. Liver
- D. Spleen
Correct Answer: C
Rationale: The correct answer is C: Liver. The liver is located in the right upper hypochondriac region of the abdomen. The duodenum (Choice A) is located in the right upper quadrant but not directly underneath the right upper hypochondriac region. The gastric pylorus (Choice B) is part of the stomach and is located more centrally in the abdomen. The spleen (Choice D) is located in the left upper quadrant of the abdomen, not underneath the right upper hypochondriac region.
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What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?
- A. Take the medication with food
- B. Avoid foods high in tyramine
- C. Report any thoughts of self-harm immediately
- D. Expect to see improvement within 24 hours
Correct Answer: C
Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.
A nurse is developing a care plan for a client with chronic pain. What interventions should be included to help manage pain?
- A. Administer pain medication around the clock
- B. Teach relaxation techniques
- C. Encourage physical activity
- D. All of the above
Correct Answer: D
Rationale: In managing chronic pain, it is essential to employ a multi-faceted approach. Administering pain medication around the clock helps maintain consistent pain relief. Teaching relaxation techniques such as deep breathing or guided imagery can help reduce muscle tension and promote relaxation, which can alleviate pain. Encouraging physical activity, tailored to the client's abilities, can help improve overall physical functioning and reduce pain perception. Therefore, combining all these interventions (pain medication, relaxation techniques, and physical activity) provides a comprehensive approach to pain management, addressing different aspects of the client's experience with chronic pain. This holistic approach is more effective than using a single intervention alone, making 'All of the above' the correct choice.
A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?
- A. Continue the transfusion at a slower rate
- B. Administer an antipyretic
- C. Stop the transfusion immediately
- D. Notify the healthcare provider
Correct Answer: C
Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.
A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.
The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?
- A. Restrict sodium intake
- B. Encourage high-protein meals
- C. Increase fluid intake
- D. Administer diuretics as prescribed
Correct Answer: D
Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.