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To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor
- A. bilirubin levels.
- B. ammonia levels.
- C. potassium levels.
- D. prothrombin time.
Correct Answer: B
Rationale: In a patient with severe cirrhosis and bleeding esophageal varices, monitoring ammonia levels is crucial. Severe liver dysfunction impairs the metabolism of protein in the GI tract, leading to increased ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Monitoring bilirubin levels is important for assessing liver function and jaundice but may not directly reflect the risk of complications from bleeding esophageal varices. Potassium levels are important but not the most critical in this scenario. Prothrombin time is essential for evaluating coagulation status but does not directly relate to the risk of complications from bleeding esophageal varices in this patient.
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When admitting a 64-year-old patient with acute pancreatitis, the healthcare provider should specifically inquire about a history of
- A. diabetes mellitus.
- B. high-protein diet.
- C. cigarette smoking.
- D. alcohol consumption.
Correct Answer: D
Rationale: In patients with acute pancreatitis, alcohol consumption is a significant risk factor and one of the most common causes in the United States. It is crucial to assess alcohol intake as it plays a key role in the development of pancreatitis. While cigarette smoking, diabetes mellitus, and high-protein diets can contribute to various health issues, they are not directly associated with the development of acute pancreatitis.
Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?
- A. The patient's urine is bright yellow
- B. The patient's stools are tan colored
- C. The patient has increased pain after eating
- D. The patient complains of chronic heartburn
Correct Answer: B
Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.
When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?
- A. Ask the patient about any arm pain.
- B. Retake the patient's blood pressure.
- C. Check the calcium level in the chart.
- D. Notify the healthcare provider immediately.
Correct Answer: C
Rationale: In this scenario, the nurse observed carpal spasms in the patient's right hand, indicating a positive Trousseau's sign, which is associated with hypocalcemia. Patients with acute pancreatitis are at risk for hypocalcemia, hence the nurse should promptly check the calcium level in the chart to assess the patient's condition. Notifying the healthcare provider comes after confirming the calcium level. There is no indication to ask about arm pain or to retake the blood pressure, as the primary concern is addressing the potential hypocalcemia.
After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?
- A. Administer hepatitis B vaccine.
- B. Test for antibodies to hepatitis B.
- C. Teach about alpha-interferon therapy.
- D. Give hepatitis B immune globulin.
Correct Answer: C
Rationale: In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.
Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?
- A. Increase activity level.
- B. Maintain adequate nutrition
- C. Establish a stable environment
- D. Identify sources of hepatitis exposure
Correct Answer: B
Rationale: The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.