Nursing Elites

1. A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: Stage 3 hepatic encephalopathy is characterized by confusion, difficulty arousing from sleep, and rigidity of extremities. These symptoms indicate advanced manifestations of hepatic encephalopathy, requiring prompt intervention and monitoring to prevent further neurological deterioration.

2. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

• A. Take the medication before bedtime.
• B. Report any weight gain of more than 2 pounds in a day.
• C. Increase your intake of high-sodium foods.
• D. Limit your fluid intake to less than 1 liter per day.

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

3. Prior to elective surgery, a patient taking warfarin should receive which instruction regarding warfarin therapy?

• A. Continue taking warfarin until the day of surgery.
• B. Stop taking warfarin three days before surgery.
• C. Switch to aspirin before surgery.
• D. Stop taking warfarin one week before surgery.

Correct answer: D

Rationale: Prior to elective surgery, a patient taking warfarin should be instructed to stop taking warfarin around one week before the procedure. This timeframe allows for the effects of warfarin to diminish, lowering the risk of excessive bleeding during surgery. Continuing warfarin until the day of surgery (Choice A) increases the risk of bleeding complications. Stopping warfarin three days before surgery (Choice B) may not provide enough time for the anticoagulant effects to subside. Switching to aspirin before surgery (Choice C) is not recommended as a substitute for warfarin in this context.

4. A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?

• A. I know it may take several weeks before I start feeling better.
• B. I should avoid drinking alcohol while taking this medication.
• C. I will stop taking the medication as soon as I feel better.
• D. I should take the medication at the same time every day.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping antidepressants abruptly can lead to withdrawal symptoms. It is essential for the client to follow the healthcare provider's instructions and complete the full course of medication even if they start feeling better to prevent potential relapse or withdrawal effects.

5. An otherwise healthy 45-year-old man presents with severe hematochezia and moderate abdominal cramping since this morning. A barium enema one year ago was normal. On examination, his blood pressure is 120/78 and pulse is 100 while lying; when standing, the blood pressure is 110/76 and pulse is 136. His hematocrit is 34. What is the most likely cause of bleeding?

• A. Diverticular bleed
• B. Duodenal ulcer
• C. Inflammatory bowel disease
• D. Vascular ectasia (watermelon stomach)

Correct answer: B

Rationale: The patient's presentation with hematochezia, moderate abdominal cramping, and hemodynamic changes (increased pulse on standing) suggests an upper gastrointestinal bleed. The drop in blood pressure and rise in pulse rate when standing indicate orthostatic hypotension, which is a sign of significant blood loss. The absence of melena does not rule out an upper GI bleed. Ulcers in the duodenal bulb can erode into the gastroduodenal artery, leading to brisk blood loss. A normal barium enema one year ago makes diverticular bleeding less likely. Inflammatory bowel disease usually does not cause severe acute GI bleeding unless there is ulceration into a vessel. Vascular ectasia, like watermelon stomach, typically presents with chronic blood loss and iron deficiency anemia, more common in older women. The absence of vomiting and the presence of hematochezia make Mallory-Weiss tear less likely in this case.

Similar Questions