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A client with chronic renal disease is admitted to the hospital for evaluation prior to a
surgical procedure. Which laboratory test indicates the client's protein status for the
longest length of time?
a. Transferrin
b. Prealbumin
c. Serum albumin
d. Urine urea nitrogen - ANSWERS-c. Serum albumin
Rationale: Serum albumin has a long half-life and is the best long-term indicator of the
body's entry into a catabolic state following protein depletion from malnutrition or stress
of chronic illness (C).
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the
procedure and take corrective action if which client reaction is noted?
a. Temperature increases from 98.8 to 99.0 F.
b. Pulse rate decreases from 78 to 52 beats/min.
c. Respiratory rate increases from 16 to 24 breaths/min.
, d. Blood pressure increases from 110/84 to 118/88 mm/Hg. - ANSWERS-b. Pulse rate
decreases from 78 to 52 beats/min.
Rationale: Parasympathetic reaction can occur as a result of digital stimulation of the
anal sphincter, which should be stopped if the client experiences a vagal response,
such as bradycardia (B).
Which statement is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to congestive heart failure.
b. Altered urinary elimination related to urinary tract infection.
c. Risk for impaired tissue integrity related to client's refusal to turn.
d. Ineffective coping related to response to positive biopsy test results. - ANSWERS-d.
Ineffective coping related to response to positive biopsy test results.
Rationale: The first part of the nursing diagnosis statement is the "diagnostic label" and
is followed by "related to" the cause, which should direct the nurse to the appropriate
interventions.
The daughter of an older woman who became depressed following the death of her
husband asks, "My mother was always well-adjusted until my father died. Will she tend
to be sick from now on?" Which response is best for the nurse to provide?
a. "She is almost sure to be less able to adapt than before."
b. "It's highly likely that she will recover and return to her pre-illness state."
c. "If you can interest her in something besides religion, it will help her stay well."
d. "Cultural strains contribute to each woman's tendencies for recurrences of
depression." - ANSWERS-b. "It's highly likely that she will recover and return to her pre-
illness state."
Rationale:
Analysis of behavior patterns using Erikson's framework can identify age-appropriate or
arrested development of normal interpersonal skills. Erikson describes the successful
resolution of a developmental crisis in the later years (older than 65-years) to include
the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face
one's own mortality and accept the death of others (B).
A client is demonstrating a positive Chvostek's sign. What action should the nurse take?