Nokea
The nurse is preparing to care for the client diagnosed with hepatitis A. Which interventions should the nurse plan to include?
- A. Teach the client to limit use of alcohol and drugs containing acetaminophen.
- B. Provide a high-protein, high-carbohydrate diet with three large meals per day.
- C. Wear gloves, mask, and gown when providing the client’s personal cares.
- D. Provide rest periods, alternating this with moderate activity during the day.
Correct Answer: D
Rationale: A. Clients with viral hepatitis should avoid all alcohol and all medications containing acetaminophen, not just limit their use. B. Clients should eat small, frequent meals with a high-carbohydrate, moderate-fat, and moderate-protein content. C. It is not necessary to wear a mask when caring for an individual with hepatitis A. A gown and gloves should be worn when in contact with blood and body fluids. D. Rest is an essential intervention to decrease the liver’s metabolic demands and increase its blood supply. Rest should be alternated with periods of activity to prevent complications and to restore health.
You may also like to solve these questions
The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement?
- A. Apply a heating pad to the abdomen for 15 to 20 minutes.
- B. Administer morphine sulfate intravenously after diluting with saline.
- C. Contact the surgeon for an order to x-ray the right shoulder.
- D. Apply a sling to the right arm, which was injured during surgery.
Correct Answer: B
Rationale: Right shoulder pain post-laparoscopic cholecystectomy is often referred pain from CO2 used in the procedure irritating the diaphragm. IV morphine relieves pain effectively. Heating pads, x-rays, or slings are inappropriate.
The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention?
- A. Bowel sounds auscultated 15 times in one (1) minute.
- B. Belching after eating a heavy and fatty meal late at night.
- C. A decrease in systolic blood pressure (BP) of 20 mm Hg from lying to sitting.
- D. A decreased frequency of distress located in the epigastric region.
Correct Answer: C
Rationale: A 20 mm Hg drop in systolic BP on positional change suggests orthostatic hypotension, possibly from bleeding, requiring immediate intervention. Normal bowel sounds, belching, and reduced pain are less concerning.
The client is admitted to the hospital complaining of malaise, abdominal discomfort, and severe diarrhea. The diagnosis is possible Crohn's disease. The client says that he has lost 27 pounds in the last four months even though he has not been dieting. To plan nursing care, which assessment data are most essential for the nurse to obtain?
- A. Approximate number and characteristics of stools each day
- B. Amount of liquid consumed daily
- C. History of previous gastric surgery
- D. Bowel sounds in the right lower quadrant
Correct Answer: A
Rationale: Frequent stools are characteristic of Crohn’s disease, and their number and characteristics are critical for assessing dehydration and skin breakdown risks.
The nurse is facilitating a support group for clients diagnosed with Crohn's disease. Which information is most important for the nurse to discuss with the clients?
- A. Discuss coping skills to assist with adaptation to lifestyle modifications.
- B. Teach about drug administration, dosages, and scheduled times.
- C. Teach dietary changes necessary to control symptoms.
- D. Explain the care of the ileostomy and necessary equipment.
Correct Answer: A
Rationale: Coping skills help clients adapt to the chronic, unpredictable nature of Crohn’s disease, addressing psychosocial needs in a support group. Medications, diet, and ileostomy care are secondary.
The client has severe liver disease. Which of the following observations is most indicative of serious problems?
- A. The client has generalized urticaria.
- B. The client is 'confused' and can no longer write his name legibly.
- C. The client is jaundiced.
- D. The client has ecchymotic areas on his arms.
Correct Answer: B
Rationale: Confusion and impaired handwriting suggest hepatic encephalopathy, a serious complication of liver disease due to ammonia buildup.