The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?

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Question 1 of 5

The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?

Correct Answer: D

Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.

Question 2 of 5

A client with chronic liver disease is prescribed lactulose. Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?

Correct Answer: B

Rationale: The correct answer is B: Serum ammonia level. Lactulose is used to lower serum ammonia levels in clients with chronic liver disease, particularly in cases of hepatic encephalopathy. Monitoring serum ammonia levels is crucial to evaluate the effectiveness of lactulose in managing hepatic encephalopathy. Choices A, C, and D are incorrect because they are not directly related to the action or evaluation of lactulose in chronic liver disease.

Question 3 of 5

An adolescent with intellectual disability is admitted for refusing to complete oral hygiene. A behavior modification program is recommended. Which reinforcement is best?

Correct Answer: D

Rationale: The best reinforcement strategy in this scenario is providing preferred activities or tokens for compliance. Positive reinforcement is effective in behavior modification programs for individuals with intellectual disabilities. Offering preferred activities or tokens serves as a reward for completing the desired behavior, in this case, oral hygiene tasks. Choices A, B, and C do not focus on reinforcing the desired behavior with positive incentives. Choice A does not provide a positive reinforcement for compliance but rather focuses on the omission of a task. Choice B uses candy, which may not be ideal for oral hygiene. Choice C involves punishment rather than positive reinforcement.

Question 4 of 5

An older adult client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

Correct Answer: A

Rationale: The correct answer is A: Recent compliance with prescribed medications. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts the management of the condition and could contribute to the current presentation. Ensuring that the client has been taking their prescribed medications can provide vital information to guide further treatment. Choices B, C, and D, although important in a comprehensive assessment, are not as immediately crucial as assessing medication compliance in this emergency situation.

Question 5 of 5

An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

Correct Answer: A

Rationale: The correct answer is A. In this scenario, the most critical information for the nurse to obtain during the initial interview is the recent compliance with prescribed medications. This is crucial to understand the client's baseline condition and management of chronic emphysema. Monitoring medication adherence can provide insights into potential exacerbating factors that may have led to the current acute symptoms. Choices B, C, and D are not as crucial in this situation. Sleep patterns, smoking history, and activity levels are important aspects of the client's overall health but do not take precedence over medication compliance when addressing acute symptoms in a client with chronic emphysema.

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