Nokea
You're caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?
- A. Asterixis
- B. Chvostek's sign
- C. Trousseau's sign
- D. Hepatojugular reflex
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:
- A. Irrigate the incision with a saline solution.
- B. Prevent bacterial infection of the incision.
- C. Measure the amount of fluid lost after surgery.
- D. Prevent accumulation of drainage in the wound.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client's bowel sounds
- B. administration of pain medication every 4 hours
- C. Evaluating the client's response to antidiarrheal medications
- D. Maintaining intake and output records
Correct Answer: D
Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.
A patient has a severe exacerbation of ulcerative colitis. Long-term medications will probably include:
- A. Antacids.
- B. Antibiotics.
- C. Corticosteroids.
- D. Histamine2-receptor blockers.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Hepatic encephalopathy develops when the blood level of which substance increases?
- A. Ammonia
- B. Amylase
- C. Calcium
- D. Potassium
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of an NG tube. Based on these findings, the nurse suspects that the client is developing which of the following mouth conditions?
- A. Stomatitis
- B. Oral candidiasis
- C. Parotitis
- D. Gingivitis
Correct Answer: C
Rationale: The correct answer is C, Parotitis. Parotitis, inflammation of the parotid glands, can occur due to the absence of saliva and dehydration, often associated with being NPO and having an NG tube. Stomatitis (choice A) is inflammation of the oral mucosa, not specifically related to absent saliva. Oral candidiasis (choice B) is a fungal infection that can occur in the mouth, not directly related to the absence of saliva. Gingivitis (choice D) is inflammation of the gums and is not typically associated with the absence of saliva and dehydration.