A nurse is caring for a client who has been admitted to the hospital.
Select the 5 actions the nurse should take.
Provide frequent rest periods for the client.
Instruct the client to avoid blowing their nose forcefully.
Assess the client s level of orientation.
Place the client on a low-carbohydrate diet.
Restrict the client's sodium intake.
Advise the client to avoid the use of soap and alcohol-based lotions.
Place the client under contact isolation.
Correct Answer : A,B,C,E,F
A: Provide frequent rest periods for the client. This is correct because the client has anaemia (low haemoglobin and hematocrit), which can cause weakness and fatigue. Rest periods can help conserve energy and prevent complications.
B: Instruct the client to avoid blowing their nose forcefully. This is correct because the client has thrombocytopenia (low platelet count), which can increase the risk of bleeding. Blowing the nose forcefully can cause nasal bleeding or rupture of blood vessels.
C: Assess the client’s level of orientation. This is correct because the client has hepatic encephalopathy (brain dysfunction due to liver failure), which can cause confusion, mood changes, and disorientation. Assessing the client’s level of orientation can help monitor the severity of hepatic encephalopathy and guide appropriate interventions.
D: Place the client on a low-carbohydrate diet. This is incorrect because a low-carbohydrate diet can worsen hepatic encephalopathy by increasing ammonia production in the gut. The client should be on a high-protein, high-calorie diet to provide adequate nutrition and prevent muscle wasting.
E: Restrict the client’s sodium intake. This is correct because the client has ascites (fluid accumulation in the abdomen) due to portal hypertension (high blood pressure in the portal vein). Restricting sodium intake can help reduce fluid retention and prevent further complications.
F Advise the client to avoid the use of soap and alcohol-based lotions. This is correct because the client has pruritus (itching) due to high bilirubin levels in the blood. Soap and alcohol-based lotions can dry out the skin and worsen pruritus. The client should use mild cleansers and moisturizers to soothe the skin.
G: Place the client under contact isolation. This is incorrect because there is no indication that the client has an infectious disease that requires contact isolation. Contact isolation is used for clients who have diseases that can be transmitted by direct or indirect contact with the client or their environment, such as Clostridioides difficile infection or methicillin-resistant Staphylococcus aureus infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason
The anterior fontanel is open is the correct answer. An expected finding in an 8-month-old infant is that the anterior fontanel (the soft spot on the top of the baby's head) is open. The fontanelles are spaces between the bones of an infant's skull that allow for the baby's brain to grow and the skull to mould during birth.
The anterior fontanel typically remains open until the baby is around 18 to 24 months old, with the closure process starting sometime after 9 months of age. Therefore, at 8 months of age, it is normal for the anterior fontanel to still be open.
Choice B reason:
Both fontanels are the same size is incorrect. Both fontanels are usually not the same size. The anterior fontanel is larger and diamond-shaped, while the posterior fontanel is smaller and triangular.
Choice C reason:
The posterior fontanel is open is incorrect. The posterior fontanel, located at the back of the baby's head, usually closes earlier than the anterior fontanel. It typically closes within the first few months after birth, so it is not expected to be open at 8 months of age.
Choice D reason
Both fontanels show molding is incorrect. Molding refers to the temporary shaping of the baby's head during birth due to the pressure exerted during the passage through the birth canal. By 8 months of age, the molding typically resolves, and the baby's head should have a more rounded appearance.
Correct Answer is ["A","B","E"]
Explanation
The correct answer is choicea, b, e.
Choice A rationale:A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.
Choice B rationale:Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.
Choice C rationale:Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.
Choice D rationale:Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.
Choice E rationale:Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.
Choice F rationale:Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.
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