Nokea
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?
- A. Decreased mental status.
- B. Elevated blood pressure.
- C. Decreased urine output.
- D. Labored respirations.
Correct Answer: A
Rationale: Hepatic encephalopathy causes decreased mental status (A) due to ammonia buildup. Elevated blood pressure (B), decreased urine output (C), and labored respirations (D) are not primary indicators.
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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 6 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which two (2) findings in the nurses' note would require immediate follow-up and reported to the physician?
- A. Rectal temperature
- B. Generalized shivering
- C. Urine output
- D. Assessment of the peripheral pulses
- E. Client reports of thirst
Correct Answer: B,C
Rationale: Generalized shivering may indicate worsening hypothermia or a cooling blanket complication, and low urine output suggests renal hypoperfusion or acute kidney injury, both requiring immediate physician notification. Temperature (A), pulses (D), and thirst (E) are expected or less urgent.
A client with thyrotoxicosis says to the nurse, 'I am so irritable. I am having problems at work because I lose my temper very easily.' Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
- A. Your behavior is caused by your not following the medical regimen.'
- B. Your behavior is caused by the effects of the disease on your thyroid.'
- C. Your behavior is caused by your not accepting your diagnosis.'
- D. Your behavior is caused by the effects of the disease on your emotional stability.'
Correct Answer: B
Rationale: Thyrotoxicosis, due to excess thyroid hormone, increases metabolism and can affect the nervous system, leading to irritability and emotional lability. This explains the client's behavior as a direct result of the disease's impact on thyroid function.
On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dL. The nurse should:
- A. Withhold all medications as ordered.
- B. Administer the insulin dose dictated by the sliding scale.
- C. Call the physician for specific orders based on the glucose level.
- D. Notify the surgery department.
Correct Answer: C
Rationale: A glucose level of 300 mg/dL indicates significant hyperglycemia, which poses risks during surgery. Calling the physician for specific orders ensures appropriate insulin administration while adhering to NPO and surgical protocols.
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:
- A. Pulse.
- B. Respirations.
- C. Blood pressure.
- D. Temperature.
Correct Answer: C
Rationale: Controlling blood pressure is the primary goal post-thrombolytic therapy to prevent hemorrhagic transformation. Pulse, respirations, and temperature are monitored but are secondary.
During the preoperative interview, the nurse obtains information about the client's medication history. Which of the following is not necessary to record about the client?
- A. Current use of medications, herbs, and vitamins.
- B. Over-the-counter medication use in the last 6 weeks.
- C. Steroid use in the last year.
- D. Use of all drugs taken in the last 18 months.
Correct Answer: D
Rationale: Recording all drugs taken in the last 18 months is excessive, as many may no longer be relevant to surgical risks. Current medications, recent over-the-counter drugs, and steroid use are critical due to their potential impact on surgery.