NUR 414 Final Exam QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Terms in this set (50)
The physician orders A. Improvement in level of consciousness
Lactulose 30 mL by mouth per
day for a client with cirrhosis. A patient with cirrhosis may experience a complication called hepatic
What finding below encephalopathy. This will cause the patient to become confused
demonstrates the (they may enter into a coma), have pungent, musty smelling
medication is working breath (fetor hepaticus), asterixis (involuntary flapping of the
effectively? hands). This is due to the buildup of ammonia in the blood,
A. which affects the brain. Lactulose can be prescribed to help
Improvement in level of decrease the ammonia levels. Therefore, if the medication is
consciousness B. working properly to decrease the level of ammonia the
Presence of patient would have improving mental status, decreased
asterixis C. ammonia blood level,
Decreased albumin decreasing or absence of asterixis, and decreased ammonia
levels D. blood level. Fruity breath is associated with DKA not hepatic
Absence of fruity breath encephalopathy.
,During the morning assessment A. Ammonia level of 68 µ/dL
of a client with cirrhosis, you
note the client is Based on the assessment findings and the fact the client has
disoriented to person and cirrhosis, the client is experiencing hepatic encephalopathy.
place. In addition, while This is due to the buildup of toxins in the
assessing the upper blood, specifically ammonia. The flapping motion of the
extremities, the client's hands hands is called "asterixis". Therefore, an increased ammonia
demonstrate a flapping motion. level would confirm these abnormal assessment findings
(Normal ammonia: 10-80)
What lab result would explain
these abnormal assessment
findings?
A.
Ammonia level of
68 µ/dL B.
Creatinine level of 2.9
mg/dL C.
Potassium level of 3.7
mmol/L D.
Calcium level of 10.9 mg/dL
A patient diagnosed with hepatitis C. Thrombocytopenia
develops splenomegaly. When
reviewing the laboratory The spleen acts as a reservoir for platelets. When the
report, which of the spleen is enlarged, as with splenomegaly, up to 90 percent
following results will the of a person's thrombocytes can be sequestered within the
healthcare provider enlarged spleen.
anticipate?
A.
Polycythe
mia B.
Leukocyt
osis C.
Thrombocytop
enia D.
Neutrophilia
A client diagnosed with viral B. Monitor the blood glucose
hepatitis develops liver
failure and hepatic Interventions for this patient include blood glucose monitoring (because
of
encephalopathy. Which of these
decreased glycogen synthesis and storage), monitoring PT and INR (because
, measures should the healthcare of
provider include in this client's decreased clotting factors), checking reflexes (because of the
plan of care? neurological effects of increased ammonia), providing
A. diet/feedings that are low in protein (to decrease ammonia
Provide high-protein
levels), and following standard precautions. The client should
feedings B.
be weighed every day.
Monitor the blood
glucose C.
Institute droplet
precautions D.
Weigh once a week
A client with cirrhosis of the liver A. Hyperkalemia
develops ascites, and the health
care provider Spironolactone (Aldactone) is a potassium-sparing diuretic
prescribes spironolactone. What that is used to treat clients with ascites; therefore, the
should the nurse monitor the nurse should monitor the client for signs and
client for? symptoms of hyperkalemia. Bruising and purpura are
A. associated with cirrhosis, not with the administration of
Hyperkale spironolactone. Spironolactone does not cause
mia B. tachycardia. Spironolactone does not cause hypoglycemia.
Tachycardi
a C.
Hypoglycem
ia D.
Ecchymosis
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Terms in this set (50)
The physician orders A. Improvement in level of consciousness
Lactulose 30 mL by mouth per
day for a client with cirrhosis. A patient with cirrhosis may experience a complication called hepatic
What finding below encephalopathy. This will cause the patient to become confused
demonstrates the (they may enter into a coma), have pungent, musty smelling
medication is working breath (fetor hepaticus), asterixis (involuntary flapping of the
effectively? hands). This is due to the buildup of ammonia in the blood,
A. which affects the brain. Lactulose can be prescribed to help
Improvement in level of decrease the ammonia levels. Therefore, if the medication is
consciousness B. working properly to decrease the level of ammonia the
Presence of patient would have improving mental status, decreased
asterixis C. ammonia blood level,
Decreased albumin decreasing or absence of asterixis, and decreased ammonia
levels D. blood level. Fruity breath is associated with DKA not hepatic
Absence of fruity breath encephalopathy.
,During the morning assessment A. Ammonia level of 68 µ/dL
of a client with cirrhosis, you
note the client is Based on the assessment findings and the fact the client has
disoriented to person and cirrhosis, the client is experiencing hepatic encephalopathy.
place. In addition, while This is due to the buildup of toxins in the
assessing the upper blood, specifically ammonia. The flapping motion of the
extremities, the client's hands hands is called "asterixis". Therefore, an increased ammonia
demonstrate a flapping motion. level would confirm these abnormal assessment findings
(Normal ammonia: 10-80)
What lab result would explain
these abnormal assessment
findings?
A.
Ammonia level of
68 µ/dL B.
Creatinine level of 2.9
mg/dL C.
Potassium level of 3.7
mmol/L D.
Calcium level of 10.9 mg/dL
A patient diagnosed with hepatitis C. Thrombocytopenia
develops splenomegaly. When
reviewing the laboratory The spleen acts as a reservoir for platelets. When the
report, which of the spleen is enlarged, as with splenomegaly, up to 90 percent
following results will the of a person's thrombocytes can be sequestered within the
healthcare provider enlarged spleen.
anticipate?
A.
Polycythe
mia B.
Leukocyt
osis C.
Thrombocytop
enia D.
Neutrophilia
A client diagnosed with viral B. Monitor the blood glucose
hepatitis develops liver
failure and hepatic Interventions for this patient include blood glucose monitoring (because
of
encephalopathy. Which of these
decreased glycogen synthesis and storage), monitoring PT and INR (because
, measures should the healthcare of
provider include in this client's decreased clotting factors), checking reflexes (because of the
plan of care? neurological effects of increased ammonia), providing
A. diet/feedings that are low in protein (to decrease ammonia
Provide high-protein
levels), and following standard precautions. The client should
feedings B.
be weighed every day.
Monitor the blood
glucose C.
Institute droplet
precautions D.
Weigh once a week
A client with cirrhosis of the liver A. Hyperkalemia
develops ascites, and the health
care provider Spironolactone (Aldactone) is a potassium-sparing diuretic
prescribes spironolactone. What that is used to treat clients with ascites; therefore, the
should the nurse monitor the nurse should monitor the client for signs and
client for? symptoms of hyperkalemia. Bruising and purpura are
A. associated with cirrhosis, not with the administration of
Hyperkale spironolactone. Spironolactone does not cause
mia B. tachycardia. Spironolactone does not cause hypoglycemia.
Tachycardi
a C.
Hypoglycem
ia D.
Ecchymosis
