Nokea
What is the primary goal of care for a client experiencing esophageal varices secondary to liver cirrhosis?
- A. Preventing infection
- B. Controlling bleeding
- C. Reducing portal hypertension
- D. Maintaining nutritional status
Correct Answer: B
Rationale: The primary goal of care for a client with esophageal varices secondary to liver cirrhosis is to control bleeding. This is because esophageal varices can lead to life-threatening hemorrhage. By controlling bleeding, we can prevent severe complications and potentially save the client's life. Preventing infection (Choice A) is important but not the primary goal in this case. Reducing portal hypertension (Choice C) is a long-term goal and may help prevent variceal bleeding in the future, but it is not the immediate priority. Maintaining nutritional status (Choice D) is important for overall health but is not the primary goal when managing acute bleeding from esophageal varices.
You may also like to solve these questions
What is the primary cause of jaundice in a client with liver cirrhosis?
- A. Decreased bile production
- B. Increased bilirubin levels
- C. Hepatic inflammation
- D. Portal hypertension
Correct Answer: B
Rationale: The primary cause of jaundice in a client with liver cirrhosis is increased bilirubin levels. Liver cirrhosis impairs the liver's ability to process bilirubin, leading to its accumulation in the bloodstream. This excess bilirubin then causes the yellow discoloration of the skin and eyes characteristic of jaundice.
Incorrect Choices:
A: Decreased bile production is not the primary cause of jaundice in liver cirrhosis. While decreased bile flow may contribute to jaundice, it is secondary to the impaired bilirubin processing.
C: Hepatic inflammation is a common feature of liver cirrhosis but is not the direct cause of jaundice in this context.
D: Portal hypertension is a complication of liver cirrhosis but is not the primary cause of jaundice.
The healthcare provider in the outpatient clinic has obtained health histories for these new patients. Which patient may need referral for genetic testing?
- A. 35-year-old patient whose maternal grandparents died after strokes at ages 90 and 96
- B. 18-year-old patient with a positive pregnancy test whose first child has cerebral palsy
- C. 34-year-old patient who has a sibling with newly diagnosed polycystic kidney disease
- D. 50-year-old patient with a history of cigarette smoking who is complaining of dyspnea
Correct Answer: C
Rationale: The correct answer is C. The patient with a sibling having newly diagnosed polycystic kidney disease may need a referral for genetic testing. Polycystic kidney disease has a genetic component, so there is a higher likelihood of the patient also having the condition. Referral for genetic testing can help in early diagnosis, management, and counseling for the patient and their family members.
Choice A is incorrect because strokes in maternal grandparents at advanced ages are not typically indicative of a need for genetic testing. Choice B is incorrect as cerebral palsy is not typically a genetic condition related to the patient's pregnancy test result. Choice D is incorrect as dyspnea in a smoking patient is more likely related to respiratory issues such as chronic obstructive pulmonary disease rather than a genetic condition.
A 75-year-old patient is admitted for pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment?
- A. Drug Abuse Screening Test (DAST-10)
- B. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
- C. Screening Test-Geriatric Version (SMAST-G)
- D. Mini-Mental State Examination
Correct Answer: C
Rationale: The most appropriate tool for the nurse to use during the admission assessment of a 75-year-old patient admitted for pancreatitis is the Screening Test-Geriatric Version (SMAST-G). This tool is specifically designed to assess for alcohol abuse in older adults, which is relevant in this case as alcohol consumption can be a risk factor for pancreatitis. The SMAST-G helps identify potential alcohol-related issues in the elderly population, allowing for appropriate interventions and care planning.
Rationale:
A: The Drug Abuse Screening Test (DAST-10) is not the most appropriate tool in this scenario as it focuses on broader drug abuse rather than specifically alcohol abuse.
B: The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is used to assess for alcohol withdrawal symptoms, not alcohol abuse itself.
D: The Mini-Mental State Examination is used to assess cognitive function, which is not directly relevant to the admission assessment for pancreatitis in this case.
Why is a low-protein diet recommended for a patient with renal failure?
- A. To prevent fluid overload
- B. To reduce nitrogenous waste
- C. To maintain electrolyte balance
- D. To prevent hyperglycemia
Correct Answer: B
Rationale: The correct answer is B: To reduce nitrogenous waste. In renal failure, the kidneys cannot effectively filter waste products like urea and creatinine, leading to their accumulation in the blood. A low-protein diet reduces the production of these nitrogenous wastes, lessening the burden on the kidneys.
A low-protein diet does not directly prevent fluid overload (A), maintain electrolyte balance (C), or prevent hyperglycemia (D) in renal failure. These functions are typically managed through other dietary modifications and treatments specific to each condition.
A patient who is receiving chemotherapy for breast cancer develops thrombocytopenia. What should the nurse include in the care plan?
- A. Encourage light exercise.
- B. Avoid intramuscular injections.
- C. Do not administer aspirin.
- D. Use a soft toothbrush for oral care.
Correct Answer: B
Rationale: The correct answer is B: Avoid intramuscular injections. Thrombocytopenia is a condition characterized by low platelet count, which can lead to impaired blood clotting. Intramuscular injections can cause bleeding and bruising due to the decreased ability of blood to clot. Therefore, it is crucial to avoid invasive procedures like intramuscular injections to prevent excessive bleeding in patients with thrombocytopenia. Encouraging light exercise (choice A) can be beneficial for overall health but may not directly address the risk of bleeding. Avoiding aspirin (choice C) is important as it can further increase the risk of bleeding. Using a soft toothbrush for oral care (choice D) is a good practice, but it does not directly address the risk associated with intramuscular injections in patients with thrombocytopenia.