A nurse is caring for a patient with cirrhosis. The nurse should monitor for signs of which of the following?

Correct Answer: A

Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.

Correct Answer: A

Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.

Correct Answer: A

Rationale: The correct answer is A: Cleanse and dress the wound. This intervention is essential as it helps prevent infection, promotes healing, and maintains a moist wound environment. Cleansing removes debris and bacteria, while dressing protects the wound from external contaminants. Administering antibiotics (choice B) is not the initial intervention for an open wound. Placing a sterile dressing (choice C) is important, but cleansing the wound first is crucial. Ensuring wound care is sterile (choice D) is important, but the primary focus should be on cleansing and dressing the wound.

Correct Answer: B

Rationale: The correct answer is B because a functional health assessment evaluates various health patterns such as roles, relationships, coping mechanisms, stress tolerance, and lifestyle choices, providing a holistic view of the individual's well-being. Vital signs and circulation (A) are typically included in a physical assessment, not a functional health assessment. Assessing specific organ abnormalities (C) would be part of a focused physical examination or diagnostic testing. Acute symptoms (D) are important to address but do not encompass the comprehensive evaluation of health patterns that a functional health assessment covers.

Correct Answer: D

Rationale: The correct answer is D: Reactions to previous hospitalizations. Before any medical procedure, it is crucial to gather information about the child's previous reactions to hospitalizations to ensure the safety and well-being of the child during the tonsil removal. This information helps healthcare providers anticipate and prevent potential complications based on past experiences. A: The child's birth weight is irrelevant to the tonsil removal procedure and does not impact the current situation. B: The age at which he started to crawl is not relevant to the tonsil removal procedure and does not provide any useful information for the medical staff. C: Whether he has had the measles is not directly related to the tonsil removal procedure and does not influence the immediate care needed for the child.

Correct Answer: C

Rationale: The correct answer is C because monitoring kidney function with regular laboratory tests is crucial in managing CKD. Regular testing helps identify changes in kidney function early, allowing for timely interventions to prevent complications. Administering diuretics (choice A) may worsen kidney function. Encouraging weight loss (choice B) may be necessary, but monitoring kidney function takes precedence. Encouraging the patient to limit fluid intake (choice D) may be necessary in some cases, but it is not the priority intervention.

Correct Answer: B

Rationale: The correct answer is B: Increased shortness of breath. During a COPD exacerbation, airflow limitation worsens, leading to increased difficulty in breathing. This is a common sign due to air trapping and inflammation in the airways. Sudden weight gain (A) is not typically associated with COPD exacerbation. Decreased heart rate (C) is not a common sign and is more likely to occur in other conditions. Increased energy levels (D) are unlikely during a COPD exacerbation as the body is under stress from impaired lung function.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the priority intervention because nitroglycerin helps dilate blood vessels, reducing chest pain in clients with heart disease. It improves blood flow to the heart, relieving ischemia. Morphine (B) can mask symptoms and should be used if pain persists after nitroglycerin. Beta blockers (C) are beneficial in chronic management but not for immediate relief. Aspirin (D) helps prevent clot formation but is not the priority in acute chest pain.

Correct Answer: D

Rationale: I must correct you on this question. The correct answer for the most appropriate action for a nurse to take when a client develops a deep vein thrombosis (DVT) is not D. The correct answer should be C: Provide anticoagulant therapy. Anticoagulant therapy is the standard treatment for DVT to prevent the blood clot from getting larger and to reduce the risk of it breaking loose and causing a pulmonary embolism. Elevating the leg and applying compression can help with symptoms but are not the primary treatment for DVT. Massage is contraindicated as it can dislodge the blood clot.