which sign might the nurse see in a client with a high ammonia level
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Nursing Elites

NCLEX-PN

Next Generation Nclex Questions Overview 3.0 ATI Quizlet

1. What sign might the nurse observe in a client with a high ammonia level?

Correct answer: A

Rationale: Coma is a sign that a nurse might observe in a client with a high ammonia level. Elevated ammonia levels can lead to hepatic encephalopathy, a condition characterized by impaired brain function, which can progress to coma. Edema (choice B) is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia (choice C) is a condition of inadequate oxygen supply to tissues and is not directly related to high ammonia levels. Polyuria (choice D) refers to excessive urination and is not a typical sign of high ammonia levels.

2. Which of the following medications should be held 24-48 hours prior to an electroencephalogram (EEG)?

Correct answer: D

Rationale: Anticonvulsants like Dilantin should be held 24-48 hours before an EEG to prevent interference with the test results. Medications such as tranquilizers, barbiturates, and other sedatives should also be avoided. Lasix, Cardizem, and Lanoxin do not belong to these categories and are not known to interfere with EEG results.

3. What is the correct instruction to give a client undergoing mammography?

Correct answer: A

Rationale: The correct instruction for a client undergoing mammography is not to use underarm deodorant. Underarm deodorant can cause confusing shadows on the X-ray film, affecting the accuracy of the mammogram. Choices B, C, and D are incorrect. While wearing comfortable clothing is advisable, it is not the primary instruction for mammography. Avoiding caffeine and bringing a list of current medications are not specific instructions related to mammography preparation and are therefore not the correct answers.

4. What can happen if a restraint is attached to a side rail or other movable part of the bed?

Correct answer: B

Rationale: Attaching a restraint to a movable part of the bed can lead to client injury if that part of the bed is moved before releasing restraints. This could result in the client getting caught or trapped, possibly causing harm. Choices C and D are incorrect because attaching restraints to movable parts of the bed is not intended to help the client stay in bed or improve posture; rather, it poses a risk of injury. Choice A is incorrect as it does not address the potential harm associated with using restraints on movable parts of the bed.

5. A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up?

Correct answer: A

Rationale: A case manager is responsible for coordinating a client's care and monitoring for unexpected outcomes. The situation that indicates an unexpected outcome and the need for immediate follow-up is when a client exhibits signs of increased intracranial pressure after a craniotomy. This indicates a deteriorating condition that requires urgent intervention. Choices B, C, and D describe expected outcomes or normal findings related to specific conditions, which do not demand immediate follow-up.

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