Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?

Correct Answer: B

Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.

Correct Answer: D

Rationale: The correct answer is D. Asking about seeing halos around lights is relevant to assessing the patient's eye health as it could indicate conditions like glaucoma or cataracts. Upper respiratory infections (A), riding in a car (B), and scuba diving (C) are not directly related to eye health assessment. By focusing on symptoms directly related to the eyes, the nurse can gather relevant information for a more accurate assessment.

Correct Answer: A

Rationale: The correct answer is A because exercising the bitten extremity can increase the spread of the venom. Choice B is correct as poisonous snake bites typically leave two fang marks. Choice C is correct as immediate severe pain and swelling are common symptoms of a poisonous snake bite. Choice D is incorrect as a tourniquet should not be used for snake bites as it can lead to complications such as tissue damage and increased risk of infection.

Correct Answer: C

Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.

Correct Answer: A

Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.

Correct Answer: A

Rationale: Step-by-step rationale: 1. Acute bronchitis is characterized by inflammation of the bronchial tubes. 2. An initial sign of acute bronchitis is a nonproductive cough due to irritation of the bronchial tubes. 3. Anorexia and labored breathing may occur later as the condition progresses. 4. Gastric ulceration is not typically associated with acute bronchitis. Therefore, choice A (Nonproductive cough) is the correct answer as it aligns with the characteristic symptom of acute bronchitis, while the other choices are not typically observed in the initial stages of the condition.

Correct Answer: C

Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure. Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications. Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow. Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.

Correct Answer: B

Rationale: The correct answer is B. After administering glucagon for hypoglycemia, the body may deplete its glycogen stores from the liver. Offering a complex carbohydrate snack will help restore liver glycogen, preventing secondary hypoglycemia. This is crucial for maintaining blood glucose levels in individuals with type 1 diabetes. Choices A, C, and D are incorrect because offering a complex carbohydrate snack is primarily aimed at restoring liver glycogen to prevent further hypoglycemic episodes, not to address nausea/vomiting, stimulate appetite, or decrease glycogen levels.

Correct Answer: B

Rationale: The correct answer is B: Health behavior. Evaluating the patient's demonstration of self-injection assesses their ability to perform a specific health-related action. This choice focuses on the patient's actions and behaviors related to their health, aligning with the scenario provided. Choice A: Health status is incorrect because it refers to the patient's current physical condition, not their ability to perform a specific health action. Choice C: Psychological self-control is incorrect as it pertains to the patient's ability to regulate their emotions and impulses, not their ability to self-administer injections. Choice D: Health service utilization is incorrect as it relates to the frequency and pattern of healthcare services used by the patient, not their ability to perform a specific health behavior.