Nokea
The nurse writes a psychosocial problem of 'risk for altered sexual functioning related to new colostomy.' Which intervention should the nurse implement?
- A. Tell the client there should be no intimacy for at least three (3) months.
- B. Ensure the client and significant other are able to change the ostomy pouch.
- C. Demonstrate with charts possible sexual positions for the client to assume.
- D. Teach the client to protect the pouch from becoming dislodged during sex.
Correct Answer: D
Rationale: Teaching pouch protection during sex addresses practical concerns, supporting sexual function and confidence. A three-month intimacy ban is unnecessary, pouch changing is unrelated to sexual function, and charts may be less practical.
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Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy?
- A. Assess the client's neurological status.
- B. Prepare to administer a loop diuretic.
- C. Check the client's stool for blood.
- D. Assess for an abdominal fluid wave.
Correct Answer: A
Rationale: Neurological assessment monitors hepatic encephalopathy progression (e.g., confusion, asterixis), guiding treatment. Diuretics, stool checks, and fluid wave assessments are less specific.
The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy?
- A. Gastrointestinal bleeding.
- B. Hypoalbuminemia.
- C. Splenomegaly.
- D. Hyperaldosteronism.
Correct Answer: A
Rationale: GI bleeding increases ammonia levels (from blood protein breakdown), a key trigger for hepatic encephalopathy. Other complications are less directly linked to this risk.
Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?
- A. History of side effects experienced from all medications.
- B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Any known allergies to drugs and environmental factors.
- D. Medical histories of at least three (3) generations.
Correct Answer: B
Rationale: NSAID use is a major risk factor for peptic ulcer disease, as these drugs can erode the gastric mucosa. While medication side effects and allergies are relevant, they are less specific, and family history is not a priority in this context.
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client's vital signs.
- B. Insert a nasogastric tube.
- C. Begin iced saline lavage.
- D. Start an IV with an 18-gauge needle.
- E. Type and crossmatch for a blood transfusion.
Correct Answer: A, D,B,C,E
Rationale: 1. Assessing vital signs evaluates hemodynamic stability (priority for bleeding). 2. Starting an IV ensures access for fluids/blood. 3. Inserting an NG tube removes blood and assesses bleeding. 4. Iced saline lavage controls bleeding. 5. Type and crossmatch prepares for transfusion.
The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is it essential to ask?
- A. When did you last eat?'
- B. Have you had surgery before?'
- C. Have you ever had this type of pain before?'
- D. What do you usually take to relieve your pain?'
Correct Answer: A
Rationale: Knowing when the client last ate is essential to minimize aspiration risk during anesthesia for anticipated appendicitis surgery.