Nokea
What assessments should the nurse prioritize for a client with portal hypertension admitted to the medical floor?
- A. Assessment of blood pressure and evaluation for headaches and visual changes
- B. Assessment for signs and symptoms of venous thromboembolism
- C. Daily weights and measurement of abdominal girth
- D. Monitoring blood glucose every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Daily weights and measurement of abdominal girth. Portal hypertension can lead to fluid retention and ascites, causing weight gain and abdominal distension. Monitoring these parameters helps assess fluid status and effectiveness of treatment.
A: Assessment of blood pressure and evaluation for headaches and visual changes is not a priority as they are not directly related to portal hypertension.
B: Assessment for signs and symptoms of venous thromboembolism is not a priority in this case unless there are specific risk factors present.
D: Monitoring blood glucose every 4 hours is not directly related to portal hypertension and is not a priority in this scenario.
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A 30-year-old woman presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?
- A. Type 1 diabetes mellitus
- B. Type 2 diabetes mellitus
- C. Diabetes insipidus
- D. Hyperthyroidism
Correct Answer: A
Rationale: Step 1: Symptoms of fatigue, polyuria, polydipsia point to diabetes.
Step 2: Hyperglycemia and ketonuria suggest uncontrolled diabetes.
Step 3: Onset in a 30-year-old woman is more common in Type 1 diabetes.
Step 4: Type 1 diabetes is characterized by autoimmune destruction of pancreatic beta cells leading to insulin deficiency.
Step 5: Treatment for Type 1 diabetes involves insulin therapy.
Summary:
- Choice B (Type 2 diabetes) is less likely due to the acute presentation and ketonuria.
- Choice C (Diabetes insipidus) does not involve hyperglycemia or ketonuria.
- Choice D (Hyperthyroidism) does not typically present with hyperglycemia and ketonuria.
When planning care for a 16-year-old with appendicitis presenting with right lower quadrant pain, what should the nurse prioritize as a nursing diagnosis?
- A. Imbalanced nutrition: Less than body requirements related to decreased oral intake
- B. Risk for infection related to possible rupture of the appendix
- C. Constipation related to decreased bowel motility and decreased fluid intake
- D. Chronic pain related to appendicitis
Correct Answer: B
Rationale: The correct answer is B: Risk for infection related to possible rupture of the appendix. This is the priority nursing diagnosis because appendicitis can lead to a life-threatening condition if the appendix ruptures. The nurse needs to monitor for signs of worsening infection such as fever and increased pain.
A: Imbalanced nutrition is not the priority as it is secondary to the risk of infection.
C: Constipation is not the priority as it is not directly related to the life-threatening complication of appendicitis.
D: Chronic pain is also not the priority as the risk of infection and potential rupture take precedence in the care of the patient.
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
- A. Two to three soft bowel movements daily
- B. Significant increase in appetite and food intake
- C. Absence of nausea and vomiting
- D. Absence of blood or mucus in stool
Correct Answer: A
Rationale: The correct answer is A: Two to three soft bowel movements daily. Lactulose is a laxative commonly used to manage hepatic encephalopathy by reducing ammonia levels through promoting bowel movements. The desired outcome of this medication is to prevent the buildup of ammonia in the bloodstream, which can exacerbate hepatic encephalopathy. Soft bowel movements indicate that the medication is effectively promoting bowel motility and reducing ammonia levels. Choices B, C, and D are incorrect as lactulose is not directly associated with increasing appetite, resolving nausea and vomiting, or eliminating blood or mucus in the stool in this context.
A client who is acutely ill has vigilant oral care included in their plan of care. What factor increases this client's risk for dental caries?
- A. Hormonal changes induced by the stress response leading to an acidic oral environment
- B. Systemic infections commonly affecting the teeth
- C. Intravenous hydration lacking fluoride
- D. Inadequate nutrition and reduced saliva production contributing to cavities
Correct Answer: D
Rationale: The correct answer is D because inadequate nutrition and reduced saliva production contribute to cavities. In acute illness, the client may not be able to consume a balanced diet, leading to nutrient deficiencies that weaken teeth. Reduced saliva flow decreases the mouth's ability to naturally clean and protect teeth. Choices A, B, and C are incorrect because hormonal changes from stress do not directly lead to acidic oral environment, systemic infections do not commonly affect teeth, and lack of fluoride from intravenous hydration is not a primary factor for dental caries.
A 28-year-old woman presents with abdominal pain, bloating, and diarrhea. She notes that her symptoms improve with fasting. She has a history of iron deficiency anemia. What is the most likely diagnosis?
- A. Irritable bowel syndrome
- B. Celiac disease
- C. Lactose intolerance
- D. Crohn's disease
Correct Answer: B
Rationale: The most likely diagnosis is Celiac disease (Choice B) due to the patient's symptoms of abdominal pain, bloating, diarrhea, and improvement with fasting, which are consistent with malabsorption seen in Celiac disease. The history of iron deficiency anemia also supports this, as it is a common complication of Celiac disease due to impaired absorption of nutrients. Irritable bowel syndrome (Choice A) typically does not improve with fasting, lactose intolerance (Choice C) does not usually cause iron deficiency anemia, and Crohn's disease (Choice D) typically presents with more severe symptoms and different patterns of improvement.