Exam Two - Practice Q's Flashcards
Which statement by a client with cirrhosis indicates that further instruction is needed about the disease?
A) The scars on my liver create problems with blood circulation
B) My liver is scarred, but the cells can regenerate themselves and repair the damage
C) Because of the scars on my liver, blood clotting and BP are affected
D) Cirrhosis is a chronic disease that has scarred my liver
B) My liver is scarred, but the cells can regenerate themselves and repair the damage
The nurse is caring for a client who has cirrhosis of the liver. The client’s latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor?
A) DVT
B) Jaundice
C) Hematemesis
D) Pressure injury
C) Hematemesis
How would the home care nurse best modify the client’s home environment to manage side effects of lactulose?
A) Obtains a walker for the client
B) Rearranges furniture to declutter the home
C) Removes throw rugs to prevent falls
D) Requests a bedside commode for the client
D) Requests a bedside commode for the client
When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure?
A) Assist the provider to insert a tracer catheter into the abdomen
B) Position the client with the head of the bed flat
C) Encourage the client to take deep breaths and cough
D) Ask the client to void prior to the procedure
D) Ask the client to void prior to the procedure
The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse’s priority assessment during client care?
A) Cardiovascular assessment
B) Abdominal assessment, including bowel sounds
C) Respiratory assessment
D) Cognitive and neurologic assessment
D) Cognitive and neurologic assessment
The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching?
A) Calcium
B) Potassium
C) Sodium
D) Magnesium
C) Sodium
The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective?
A) Increased BP
B) Decreased weight
C) Increased pulse
D) Decreased pain
B) Decreased weight
The nurse is teaching a client and family about home care following a transjugular intrahepatic portal systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately?
A) Decreased ascitic fluid
B) Changes in consciousness or behavior
C) Fatigue and weakness
D) Decreased pulse rate
B) Changes in consciousness or behavior
Client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status and/or behavior.
The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse?
A) These interventions help to reduce the ammonia level
B) These interventions help to prevent heart failure
C)These interventions help the client’s jaundice improve
D) These interventions help to prevent nausea and vomiting
A) These interventions help to reduce the ammonia level
The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client’s hepatitis A?
A) Being exposed to blood or blood products
B) Eating contaminated food or water
C) Having unprotected sex
D) Sharing needles for illicit drugs
B) Eating contaminated food or water
When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B?
A) Clients who work with shellfish
B) Clients with elevations of aspartate aminotransferase and alanine aminotransferase
C) Men who engage in sex with men
D) Clients traveling to a third-world country
C) Men who engage in sex with men
It is essential that the nurse monitor the client retuning from hepatic artery embolization for hepatic cancer for which potential complication?
A) Right shoulder pain
B) Bone marrow suppression
C) Polyuria
D) Bleeding
D) Bleeding
What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection?
A) Drink only bottled water and avoid ice
B) Avoid sharing the bathroom with the client
C) Members of the household must not share toothbrushes
D) The client must not consume alcohol
C) Members of the household must not share toothbrushes
Which action by the nurse would most likely help to relieve symptoms associated with ascites?
A) Monitoring serum albumin levels
B) Lowering the head of the bed
C) Administering oxygen therapy
D) Administering intravenous fluids
C) Administering oxygen therapy
The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor?
A) Acute kidney injury
B) Hypertension
C) Pulmonary edema
D) Infection
D) Infection
When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? SATA
A) Elevated magnesium
B) Swollen abdomen
C) Prolonged partial thromboplastin time
D) Elevated amylase level
E) Currant jelly stool
F) Icterus of skin
B) Swollen abdomen
C) Prolonged partial thromboplastin time
F) Icterus of skin
When assessing a client with hepatitis B, the nurse anticipates which assessment findings? SATA
A) Right upper quadrant tenderness
B) Itching
C) Recent influenza infection
D) Brown stool
E) Tea-colored urine
A) Right upper quadrant tenderness
B) Itching
E) Tea-colored urine
When caring for a client with portal hypertension, the nurse assesses for which potential complications? SATA
A) Esophageal varices
B) Ascites
C) Hematuria
D) Hemorrhoids
E) Fever
A) Esophageal varices
B) Ascites
D) Hemorrhoids
The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? SATA
A) Smoking
B) Alcohol
C) Illicit drugs
D) Acetaminophen
E) Sodium
F) Protein
A) Smoking
B) Alcohol
C) Illicit drugs
D) Acetaminophen
The nurse is caring for a client who has been diagnosed with cirrhosis. Which lab result(s) would the nurse expect for this client? SATA
A) Increased serum bilirubin
B) Increased lactate dehydrogenase
C) Decreased serum albumin
D) Increased serum alanine aminotransferase
E) Increased aspartate aminotransferase
F) Increased serum ammonia
A) Increased serum bilirubin
B) Increased lactate dehydrogenase
C) Decreased serum albumin
D) Increased serum alanine aminotransferase
E) Increased aspartate aminotransferase
F) Increased serum ammonia
A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is priority for the client at this time?
A) Positioning the client to maximize ventilation potential
B)Taking vital signs Q2hours
C) Inserting an indwelling urinary catheter
D) Monitoring the client’s nutritional status
A) Positioning the client to maximize ventilation potential
To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority?
A) Nutritional therapy
B) Physical therapy
C) Respiratory therapy
D) Occupational therapy
C) Respiratory therapy
A client has been diagnosed with primary progressive multiple sclerosis (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates a need for further teaching?
A) It’s important I work out in the afternoon so my muscles are warmed up
B) I can alternate wearing my eye patch between eyes for double vision
C) I should keep my home clutter free so I don’t fall
D) I always keep my medications in the same place
A) It’s important I work out in the afternoon so my muscles are warmed up
A client returns to the neurosurgical floor after undergoing a traditional anterior cervical diskectomy and fusion (ACDF). What is the nurse’s first action?
A) Check the client’s ability to void
B) Administer pain medication
C) Assist with ambulation
D) Assess airway and breathing
D) Assess airway and breathing