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: Eggs. Eggs are considered a complete protein because they contain all nine essential amino acids required by the body. These amino acids are necessary for various bodily functions, such as muscle growth and repair. Corn (A), peanuts (C), and sunflower seeds (D) are incomplete proteins as they lack one or more essential amino acids. Therefore, eggs are the best choice for a complete protein source compared to the other options provided.

Correct Answer: D

Rationale: The correct answer is D because it directly asks for specific information about past hospitalizations, prompting Mr. Y to recall the last time he was admitted for chest pain. This question is open-ended, allowing Mr. Y to provide detailed information voluntarily. A is incorrect as it assumes Mr. Y has been hospitalized without directly asking for that information. B is a better choice but lacks specificity in requesting details about past hospitalizations. C is inappropriate as it assumes permission to access medical records without Mr. Y's consent.

Correct Answer: A

Rationale: The correct answer is A because an auditory hallucination involves hearing something that is not actually present. In this scenario, the man is hearing his dead wife talking to him, which is a perception without an external auditory stimulus. This illustrates an auditory hallucination. Choice B is incorrect as it describes a visual hallucination, seeing the doorbell indicator light up and hearing the bell ring. Choice C is also incorrect as it describes a visual misperception, seeing a man in the closet that turns out to be a dry cleaning bag. Choice D is incorrect as it describes a misinterpretation of a visual stimulus, mistaking a blanket for a dog.

Correct Answer: B

Rationale: The correct answer is B: Hamburgers. Clients with hypercholesterolemia should decrease their intake of saturated fats and cholesterol. Hamburgers are typically high in saturated fats and cholesterol due to the ground beef patty and cheese. Broiled catfish (A) is a lean protein source and can be a healthier option. Wheat bread (C) is a good source of fiber and can help lower cholesterol levels. Fresh apples (D) are a healthy choice low in saturated fats and cholesterol. Therefore, hamburgers should be decreased in the diet to manage hypercholesterolemia effectively.

Correct Answer: D

Rationale: Step 1: Establish rapport by showing interest in the patient's well-being. Step 2: Emphasize continuity of care by referencing the previous visit. Step 3: Encourage open communication about any changes or concerns. Step 4: Initiate discussion on the patient's health status since the last visit. Summary: A - Too broad and not focused on the patient's own health. B - Assumes the patient has a specific reason for the visit. C - Assumes the patient has hypertension and may not be relevant. D - Encourages discussion on the patient's health status and continuity of care.

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics to manage fluid retention. In heart failure, fluid overload can worsen symptoms and lead to complications. Diuretics help reduce excess fluid in the body, relieving strain on the heart. This intervention helps improve cardiac function and alleviate symptoms. Choice B (Encouraging increased physical activity) may be beneficial in some cases, but in heart failure, excessive physical activity can strain the heart further. Choice C (Providing a low-sodium diet) is important in managing heart failure, but diuretics would be more critical initially to address immediate fluid retention. Choice D (Encouraging high-potassium foods) is important for overall health but not the priority in managing heart failure.

Correct Answer: A

Rationale: Step 1: Respect and compassion are essential in end-of-life care to support patients emotionally. Step 2: Nurses need to show empathy and understanding towards patients and their families. Step 3: Providing comfort and dignity in the final stages of life is crucial. Step 4: Assessing and intervening (Choice B) is important but not the primary competency in end-of-life care. Step 5: Setting goals and dynamic changes to care (Choice C) may be relevant but not as fundamental as respect and compassion. Step 6: Keeping sad news away (Choice D) goes against transparency and trust-building in end-of-life care.

Correct Answer: C

Rationale: The correct answer is C: Apply an airtight dressing. This is the first priority because it helps prevent air from entering the chest cavity, which can cause a tension pneumothorax. A tension pneumothorax can rapidly lead to respiratory distress and cardiac arrest. Applying an airtight dressing helps stabilize the condition until further medical intervention can be provided. Incorrect choices: A: Performing needle decompression is not the first priority as it is indicated for a tension pneumothorax once it has developed, not as a preventive measure. B: Applying a sterile dressing is important but not the first priority when dealing with a gunshot wound to the chest as sealing the wound to prevent air entry is more critical. D: Monitoring the client's ECG is not the first priority in this situation as addressing the potential tension pneumothorax takes precedence over monitoring the client's heart rhythm.