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

Correct Answer: B

Rationale: The correct answer is B, Hepatic encephalopathy. In cirrhosis, the liver is unable to detoxify ammonia, leading to its accumulation and causing neurological symptoms. Monitoring for signs such as confusion, altered mental status, and asterixis is crucial. Acute renal failure (A) is not directly related to cirrhosis but may occur as a complication. Acute pancreatitis (C) is not a typical complication of cirrhosis. COPD (D) is a respiratory condition and not directly associated with cirrhosis.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.

Correct Answer: B

Rationale: The correct answer is B because encouraging early ambulation is a priority post-operative intervention for a patient following a hip replacement. Early ambulation helps prevent complications such as blood clots, muscle weakness, and pneumonia. It also promotes circulation and aids in the patient's recovery. Administering pain medications (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial, but ambulation takes precedence. Providing wound care (D) is essential but can be done after ensuring the patient's mobility.

Correct Answer: C

Rationale: The correct answer is C: Assessing the patient's respiratory status. After administering pain medication, especially opioids, it is crucial to monitor the patient's respiratory status due to the risk of respiratory depression. This assessment is a priority because respiratory depression can be life-threatening. Other choices are not as immediate: A, assessing for addiction, can be done but is not as critical at this moment; B, assessing pain level, is important but comes after ensuring the patient's safety; D, assessing for infection, is not directly related to the immediate effects of pain medication.

Correct Answer: C

Rationale: The correct answer is C: decrease maternal fluids. When fetal distress is indicated, decreasing maternal fluids helps prevent further stress on the fetus by reducing the volume of amniotic fluid. This can help improve blood flow to the placenta and oxygen delivery to the baby. Increasing maternal fluids (choice A) can worsen the situation by potentially increasing amniotic fluid volume and further compromising fetal oxygenation. Administering oxygen (choice B) is important to improve oxygen supply to the fetus. Turning the mother (choice D) can help relieve pressure on the baby but is not the primary action when fetal distress is indicated.

Correct Answer: D

Rationale: The correct answer is D because polio, pertussis, and measles are highly infectious diseases that can have severe consequences if not prevented through vaccination. Polio can cause paralysis, pertussis can be fatal in infants, and measles can lead to complications like pneumonia and encephalitis. Emphasizing these vaccines can significantly reduce the risk of outbreaks and protect public health. Choice A is incorrect because HPV and genital herpes are sexually transmitted infections, and although important, they are not typically prevented through vaccines like polio, pertussis, and measles. Choice B is incorrect because pneumonia, HIV, and mumps, while serious diseases, do not have vaccines that are as universally recommended for prevention as polio, pertussis, and measles. Choice C is incorrect because syphilis and gonorrhea are sexually transmitted infections, and pneumonia is not typically prevented through vaccination as effectively as polio, pertussis, and measles.

Correct Answer: C

Rationale: The correct answer is C: Using biased or leading questions. This question is biased and leading because it assumes that the patients attending the workshop do not engage in smoking, drinking, or drug use. It may influence the patients to provide inaccurate information if they feel pressured to conform to societal expectations. In health assessments, it is important to ask open-ended, non-judgmental questions to gather accurate and comprehensive information. Incorrect choices: A: Talking too much - This choice is not relevant to the question as it does not address the issue of biased or leading questions. B: Using confrontation - This choice does not apply as the question does not involve confronting the patients. D: Using blunt language to deal with distasteful topics - While the question may be blunt, the main issue is the bias and leading nature of the question, not its bluntness.

Correct Answer: C

Rationale: The correct intervention for hyperkalemia is to administer insulin (Choice C). Insulin drives potassium into cells, lowering serum potassium levels. This is effective in acutely reducing high potassium levels. Administering calcium gluconate (Choice A) is used for stabilizing cardiac membranes in hyperkalemia but does not lower potassium levels. Sodium bicarbonate (Choice B) is used for metabolic acidosis, not hyperkalemia. Furosemide (Choice D) is a loop diuretic that can lead to potassium loss but is not the primary intervention for hyperkalemia.