With Complete Solutions
A nurse is caring for a patient who has cirrhosis. what medications should the nurse administer to this patient? - Correct Answer Diuretic, beta-blocker agent, & lactulose
a nurse is caring for a client who has a new diagnosis of hepatitis C. which laboratory findings should the nurse expect? - Correct Answer positive EIA test
what are indicators of hepatic encephalopathy? - Correct Answer change in orientation, asterixis, & fetor hepaticus
acute graft rejection post liver transplant typically occurs how many days after surgery? - Correct Answer 4-10 days
a nurse is providing teaching to a client who has a diagnosis of hepatitis A. which of the following statements by the client indicates an understanding of the teaching?
a. I am unable to donate blood
b. I will need to get a booster shot of immune serum globulin every year
c. I should stop eating raw clams
d. I can develop this disease by getting a tattoo - Correct Answer c. I should stop eating raw clams
A nurse does an assessment on a client after an endoscopic retrograde cholangiopancreatography (ERCP). The nurse reports to the health care provider which finding?
a. Distended firm abdomen
b. Absence of a gag reflex
c. Left-sided hip soreness
Colicky abdominal pain - Correct Answer a. distended firm abdomen
The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D - Correct Answer a. Hepatitis A
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
a. Dorsiflex the client's foot
b. Measure the abdominal girth
c. Ask the client to extend their arms d. Instruct the client to learn forward - Correct Answer c. Ask the client to extend their arms
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following?
a. Malaise
b. Dark stools
c. Weight gain
d. LUQ pain - Correct Answer a. Malaise
Which of the follow is NOT a treatment for an upper GI tract bleed?
a. Octreotide
b. Endoscopy
c. Colon resection
d. Balloon tamponade - Correct Answer c. Colon resection
Which is the priority nursing action while caring for a client with esophageal varices?
a. Assessing for hemorrhage
b. Controlling blood pressure
c. Encouraging nutritional intake
d. Teaching the client about varices - Correct Answer a. Assessing for hemorrhage
A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the findings is the priority for the nurse to report to the MD?
a. Temperature 102.9 F
b. Headache
c. Constipation
d. Dry mouth - Correct Answer a. Temperature 102.9 F
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy, which of the following laboratory findings should the nurse monitor prior to the procedure?
a. PTT
b. Lipase
c. Bilirubin
d. Calcium - Correct Answer a. PTT
a nurse is observing a client with schizophrenia in the dayroom. Another client asks him if several items of clothing match. He replies, "A match. I like matches. They are givers of light, the light of the world. Let your light shine on" the nurse should identify these statements as which of the following speech alterations?
a. Clang association
b. Echolalia
c. Word salad
d. Associative looseness - Correct Answer d. Associative looseness A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan?
a. Contact the triage officer
b. Implement the client tracking system
c. Ask the communications officer to release a press statement
d. Notify the incident commander - Correct Answer d. Notify the incident commander
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?
a. I am a superhero and am immortal
b. I am no one, and everyone is me
c. I feel monsters pinching me all over
d. I know that you are stealing my thoughts - Correct Answer b. I am no one, and everyone is me
Which diagnostic test will confirm a diagnosis of cirrhosis?
a. Albumin level
b. Bromsulphthalein dye excretion
c. Liver biopsy
d. Liver enzyme tests - Correct Answer c. Liver biopsy
What is the nurse's priority while caring for a client with spontaneous bacterial peritonitis?
a. Fluid and electrolyte
b. Gastric irrigation
c. Pain management
d. Psychosocial issues - Correct Answer a. Fluid and electrolyte
A 23 yr old female admitted to the unit after being found unresponsive by paramedics. No overt signs or symptoms of injury or physical abuse. After starting an intravenous drip, you accidentally stick yourself with the same needle used for venipuncture.
a. Based on the preceding information, to what type of hepatitis would you most likely be exposed?
i. Hepatitis A
ii. Hepatitis B and C
iii. Hepatitis D
iv. No risk of hepatitis acquisition - Correct Answer ii. Hepatitis B and C
A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor" Which of the following actions should the nurse take first?
a. Use therapeutic communication to discuss the hallucination with the client
b. Initiate one-to-one observation of the client
c. Focus the client on reality