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Question 1 of 5

A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:

Correct Answer: C

Rationale: Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.

Question 2 of 5

A client with a history of Cushing’s syndrome is admitted with complaints of weight gain. The nurse should expect the client to have:

Correct Answer: A

Rationale: Cushing’s syndrome causes excess cortisol, leading to moon face, central obesity, and weight gain.

Question 3 of 5

A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of 'not feeling well.' At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:

Correct Answer: C

Rationale: Four ounces of orange juice will raise blood sugar to a normal level and sustain it until dinner, preventing hypoglycemia. The other options either raise blood sugar too high or are insufficient.

Question 4 of 5

A client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:

Correct Answer: A

Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.

Question 5 of 5

The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?

Question Image

Correct Answer: A, B, C, D, E, G

Rationale: Elevated commode seats (
A), removing rugs (
B), grab bars (
C), medic alert monitors (
D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.

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