A patient with a history of cirrhosis is at risk for developing hepatic encephalopathy. Which nursing intervention is most effective in preventing and managing hepatic encephalopathy?

Correct Answer: A

Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.

Correct Answer: A

Rationale: The development of autoantibodies such as antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in systemic lupus erythematosus (SLE) is primarily attributed to a loss of self-tolerance. Self-tolerance refers to the immune system's ability to recognize and differentiate self-antigens from foreign antigens. In individuals with SLE, there is a breakdown in immune tolerance mechanisms, leading to the production of autoantibodies against self-antigens like nuclear components (e.g., DNA, RNA, histones). This loss of self-tolerance results in the immune system targeting and attacking its tissues, leading to the systemic inflammation and tissue damage characteristic of SLE. The presence of elevated levels of ANA and anti-dsDNA antibodies in this patient suggests an autoimmune response against nuclear material, further supporting the role of self-tolerance breakdown in SLE

Correct Answer: B

Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.

Correct Answer: D

Rationale: Regular health check-ups play a crucial role in the prevention, early detection, and management of health issues, especially for the elderly. By ensuring that the elderly receive regular health check-ups, healthcare providers can monitor their health status, detect any potential health problems early on, and provide appropriate medical interventions. This proactive approach can help protect the elderly from developing serious health issues or complications. Additionally, regular health check-ups can also promote overall health and well-being, allowing healthcare professionals to address any existing health concerns and provide necessary treatments or recommendations to maintain the elderly's health and quality of life.

Correct Answer: A

Rationale: In prioritizing nursing diagnoses, the nurse should consider issues that pose the greatest risk to the patient's immediate well-being. A fluid volume deficit can lead to dehydration and potentially life-threatening complications, making it a priority to address. It is crucial to restore fluid balance to maintain normal body functions and prevent further deterioration of the patient's condition. Ensuring adequate hydration is essential for the patient's overall health and recovery. The other options, such as risk for pain, coping, and body image disturbances, while important, are not as urgent as addressing a fluid volume deficit.

Correct Answer: D

Rationale: Nephrolithiasis refers to the formation of stones within the kidney or urinary tract. The most common types of kidney stones are either composed of calcium oxalate or calcium phosphate. When these stones form within the renal collecting system, they can lead to symptoms such as flank pain, hematuria, and urinary obstruction. Ureteropelvic junction (UPJ) obstruction and ureterovesical junction (UVJ) obstruction are specific types of blockages within the urinary system that can be caused by kidney stones but are not characteristic of the stone formation itself. Renal colic is the term used to describe the severe pain associated with the passage of a kidney stone through the ureter.

Correct Answer: B

Rationale: The primary purpose of a cervical collar in the management of trauma patients is to immobilize the cervical spine. This is crucial in cases of suspected cervical spine injury to prevent any further damage and to maintain spinal stability. By providing support and restricting movement in the cervical spine region, a cervical collar helps prevent potential spinal cord injuries and associated neurological deficits. It is essential to immobilize the cervical spine until a thorough evaluation can be carried out to determine the extent of injury, as any movement of the spine during this period can worsen the damage.

Correct Answer: D

Rationale: Demerol (meperidine hydrochloride) is an opioid analgesic commonly used as a preoperative medication to decrease intra-operative anesthetic requirements and provide analgesia. Opioids like Demerol act on the central nervous system to reduce pain sensations, making it an effective choice for preoperative pain management. This can help decrease the amount of anesthesia needed during surgery, leading to better pain control and overall patient comfort during and after the procedure. Celebrex, acetaminophen, and ibuprofen are also used for pain management, but they do not have the same potency and mechanism of action as opioids like Demerol for reducing intra-operative anesthetic requirements.

Correct Answer: B

Rationale: The nurse's best approach to address the patient's fear of pain is to provide accurate information about pain management strategies and options. In doing so, the nurse can help alleviate the patient's concerns by empowering them with knowledge and potential solutions for managing pain during and after the procedure. By acknowledging the patient's fear and addressing it with practical information, the nurse can build trust, reduce anxiety, and create a more supportive and collaborative environment for the patient. Dismissing, ignoring, or invalidating the patient's fear would not be effective in addressing the underlying concerns and could potentially lead to increased distress and resistance to the recommended procedure.