You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?

Correct Answer: A

Rationale: In caring for a patient with hepatic encephalopathy like Sally, administering a lactulose enema as ordered (Option A) is crucial. Lactulose helps reduce blood ammonia levels by promoting its excretion in the stool, thereby alleviating symptoms of hepatic encephalopathy. Encouraging a protein-rich diet (Option B) is contraindicated as it can increase ammonia production. Administering sedatives (Option C) is also not recommended as they can worsen the patient's mental status. Encouraging ambulation (Option D) is beneficial for general health but does not directly address the pathophysiology of hepatic encephalopathy. Understanding these principles is essential in providing safe and effective care to patients with hepatic encephalopathy, demonstrating the importance of clinical reasoning and evidence-based practice in medical-surgical nursing.

Correct Answer: C

Rationale: In the context of a patient with achalasia, a condition characterized by impaired esophageal motility leading to difficulty swallowing, the correct answer is C) Eat meals sitting upright. This is because eating in an upright position helps gravity assist in moving food down the esophagus, making it easier for the patient to swallow. Option A) Swallow foods while leaning forward is incorrect because leaning forward can actually worsen symptoms by causing food to get stuck in the esophagus due to the lack of proper esophageal motility in achalasia. Option B) Omit fluids at mealtimes is incorrect as fluids can help facilitate the passage of food through the esophagus and into the stomach, which is beneficial for a patient with achalasia. Option D) Avoid soft and semisoft foods is incorrect because softer textures are actually easier for a patient with achalasia to swallow compared to harder or more solid foods that may get stuck in the esophagus. Educationally, understanding the physiological basis of achalasia and how different dietary and positional strategies can impact a patient's ability to swallow effectively is crucial for providing optimal care and improving nutritional intake in these patients. By teaching students the rationale behind these interventions, they can apply evidence-based practices in their nursing care to promote better outcomes for patients with gastrointestinal disorders like achalasia.

Correct Answer: C

Rationale: In the case of a patient with acute pancreatitis like Britney, the correct laboratory findings that are expected to be abnormal are serum amylase and lipase (Option C). Amylase and lipase are pancreatic enzymes, and their elevation in the blood indicates damage to the pancreas, which is a hallmark of acute pancreatitis. Option A, Serum creatinine and BUN, are markers of kidney function and are not specifically related to pancreatitis. Options B and D, Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and cardiac enzymes, are associated with liver and heart function respectively, and are not typically elevated in acute pancreatitis. In an educational context, understanding the specific laboratory findings associated with different conditions is crucial for accurate diagnosis and appropriate treatment. By knowing which markers to look for, nurses can provide better care, monitor patient progress, and collaborate effectively with the healthcare team to manage the patient's condition.

Correct Answer: D

Rationale: In a patient with Crohn's disease experiencing prolonged diarrhea, the correct answer is D) 1.03 for urine specific gravity. This high specific gravity indicates concentrated urine due to dehydration from fluid loss through diarrhea. Dehydration leads to increased solute concentration in the urine, raising its specific gravity. Option A) 1.005 is too low for a dehydrated patient with diarrhea. Option B) 1.011 and C) 1.02 are also lower values, indicating less concentrated urine compared to option D. In a dehydrated state, urine specific gravity tends to be higher than normal due to the body conserving water. In an educational context, understanding how dehydration affects urine specific gravity is crucial for nurses caring for patients with gastrointestinal conditions like Crohn's disease. Monitoring urine specific gravity helps assess hydration status and guide fluid replacement therapy. Nurses must recognize abnormal values to intervene promptly and prevent complications related to dehydration.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Splint the incision if he can't avoid sneezing or coughing. This instruction is crucial after a herniorrhaphy (surgical repair of a hernia) to minimize the risk of complications. By splinting the incision during sneezing or coughing, David can prevent excessive strain on the surgical site, reducing the chances of wound dehiscence or hernia recurrence. Option A, which suggests avoiding pain medication, is incorrect because adequate pain management is essential postoperatively to promote patient comfort and mobility, ultimately improving outcomes. Pain control also helps prevent complications such as atelectasis due to shallow breathing. Option B, coughing and deep breathing Q2H, is incorrect immediately after a herniorrhaphy as it can increase intra-abdominal pressure and strain on the incision, potentially leading to complications like wound dehiscence or hernia recurrence. Option D, applying heat to scrotal swelling, is unrelated to the patient's risk of complications post-herniorrhaphy and does not address the specific care needed to minimize complications following this surgical procedure. Educationally, this rationale emphasizes the importance of proper postoperative care after a herniorrhaphy to prevent complications and promote optimal healing. By understanding the rationale behind each option, students can grasp the significance of specific nursing interventions in the context of surgical procedures, enhancing their clinical decision-making skills.