A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?

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Question 1 of 5

A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?

Correct Answer: B

Rationale: Hemorrhage risk from esophageal varices is life-threatening in portal hypertension.

Question 2 of 5

When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?

Correct Answer: D

Rationale: Facing the client maintains engagement while the interpreter translates.

Question 3 of 5

A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to

Correct Answer: A

Rationale: Immediate provider notification ensures rapid intervention for suicide risk.

Question 4 of 5

Which factor should a nurse prioritize when choosing a suitable patient gown?

Correct Answer: C

Rationale: Ease of access for nursing procedures is the top priority when selecting a patient gown, as it ensures efficient care delivery such as wound checks, IV adjustments, or catheter management without compromising patient dignity or comfort. Aesthetic appeal might boost morale but doesn't impact functionality. The nurse's preference is irrelevant; the focus is on patient needs and workflow. Matching the patient's favorite color could enhance comfort emotionally, but it's secondary to practical considerations. Gowns with ties or openings are designed to balance accessibility with coverage, making this factor critical in a clinical setting where timely interventions can affect outcomes.

Question 5 of 5

Which action should a nurse take when a patient is experiencing dyspnea?

Correct Answer: A

Rationale: Elevating the head of the bed helps a patient with dyspnea by reducing chest pressure, allowing better lung expansion, and easing breathing effort through gravitational assistance. This position, often Fowler's, is a first-line intervention for respiratory distress. Large doses of pain medication might sedate the patient, worsening breathing, and aren't indicated unless pain is the cause. Dim lighting may calm them but doesn't address the physical issue. Vigorous exercise is dangerous during dyspnea, as it increases oxygen demand. Nurses prioritize this simple, effective adjustment to stabilize breathing and improve oxygenation, often before further medical steps.

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