Question

The nurse plans discharge education for a client with acute hepatitis A. What statement should the nurse plan to include in the discharge instructions?

Answer 1

Correct Answers:

Plan rest periods between activities to promote liver cell regeneration.

Rationale :

✅Hepatitis A causes acute liver inflammation, leading to fatigue and decreased energy, making rest essential for recovery.

😴Scheduling rest periods helps reduce metabolic demand on the liver, supporting liver cell regeneration and healing.

🚫Acetaminophen is hepatotoxic and should be avoided because it can worsen liver damage in hepatitis.

💊Antiviral medications are not used for Hepatitis A since it is a self-limiting infection, and fluid restriction is inappropriate because adequate hydration is necessary.

📌Core message

Rest and avoidance of liver stressors are essential for recovery in acute hepatitis A.

Answer 2

Correct Answers:

Install handrails in the bathtub to help the client avoid falling during showers.

Rationale :

🧠Alzheimer’s disease leads to cognitive decline, impaired judgment, and decreased coordination, increasing the client’s risk for injury, especially in high-risk areas like the bathroom.

🚿Installing handrails in the bathtub provides physical support and stability, which directly helps prevent falls and injuries during bathing activities.

🚫Turning off lights at night can worsen confusion and disorientation, increasing the risk of falls and agitation rather than promoting safety.

⚠️Using restraints is unsafe and inappropriate, and placing throw rugs increases fall risk, making environmental modification the safest approach for maintaining home safety.

📌Core message

Environmental safety modifications, such as installing handrails, are essential to prevent falls and injuries in clients with Alzheimer’s disease.

Answer 3

Correct Answers:

Confusion

Rationale :

🧠Increased intracranial pressure (ICP) impairs cerebral perfusion, leading to altered level of consciousness such as confusion, which is an early and critical sign.

⚠️Changes in mental status occur before other neurological deficits, making confusion a key indicator of worsening ICP.

🌡️Findings like fever, rash, and neck stiffness are associated with meningitis, but they do not specifically indicate increased ICP.

🚨Early recognition of confusion allows prompt intervention to prevent brain herniation and irreversible damage.

📌Core message

Altered mental status (confusion) is an early and critical sign of increased intracranial pressure.

Answer 4

Correct Answers:

Neck stiffness

Rationale :

🚗A basilar skull fracture with CSF leak increases risk for meningitis, making neck stiffness a serious complication requiring immediate reporting.

🦠Neck stiffness indicates possible meningeal irritation, which is a medical emergency.

👁️Battle’s sign and periorbital bruising are expected findings in basilar skull fractures and do not indicate acute deterioration.

⚠️Prompt recognition of infection signs is essential to prevent neurological decline and sepsis.

📌Core message

Neck stiffness signals possible meningitis, a life-threatening complication of basilar skull fracture.

Answer 5

Correct Answers:

Are you prescribed nitroglycerin for cardiac problems?

Rationale :

💊Medications for erectile dysfunction (e.g., sildenafil) cause vasodilation, which can dangerously interact with nitrates.

❤️Concurrent use with nitroglycerin can lead to severe hypotension and cardiovascular collapse.

⚠️Identifying contraindications is critical before initiating ED medications to ensure patient safety.

🔍Other questions assess history but do not identify life-threatening drug interactions.

📌Core message

Nitrates are contraindicated with ED medications due to risk of severe hypotension.

Answer 6

Correct Answers:

Elevate the head of the bed to 45–90 degrees.

Rationale :

⚡The client is experiencing autonomic dysreflexia, a life-threatening condition causing severe hypertension.

🛏️The first action is to elevate the head of the bed, which promotes venous pooling and reduces blood pressure.

🚫Addressing triggers like bladder distention comes after initial stabilization.

🚨Immediate positioning helps prevent stroke, seizures, or cardiac complications.

📌Core message

Positioning (HOB elevation) is the first step in managing autonomic dysreflexia to reduce BP.

Answer 7

Correct Answers:

Tell me what you are most concerned about.

Rationale :

🗣️This response uses therapeutic communication, encouraging the client to express feelings and concerns.

🤝Open-ended questions promote emotional support and trust, especially in terminal illness.

🚫Other responses are dismissive or redirect the client away from expressing concerns.

💬Understanding the client’s perspective helps guide individualized care and coping strategies.

📌Core message

Open-ended communication supports emotional needs in oncology clients.

Answer 8

Correct Answers:

The Murphy sign

Rationale :

✅Cholecystitis involves inflammation of the gallbladder, causing pain with inspiration when palpating the RUQ (Murphy sign).

👨‍⚕️A positive Murphy sign is a hallmark clinical finding for gallbladder inflammation.

⚠️Other signs like rebound tenderness relate more to peritonitis, not cholecystitis.

🔍Recognizing this sign helps confirm clinical diagnosis.

📌Core message

Murphy sign is a key indicator of cholecystitis.

Answer 9

Correct Answers:

I should eat foods that are low in fiber such as red meat.

Rationale :

🧠Hepatic encephalopathy is worsened by high protein intake, especially from red meat, due to ammonia buildup.

🍖Red meat increases nitrogen waste, worsening neurological symptoms.

💊Lactulose and adequate fluids help reduce ammonia levels and prevent complications.

⚠️The statement shows misunderstanding of dietary restrictions needed to prevent encephalopathy.

📌Core message

High protein (red meat) worsens hepatic encephalopathy due to ammonia buildup.

Answer 10

Correct Answers:

Avoid eating food high in fiber and using stool softeners.

Rationale :

🦠Genital herpes causes lesions that may be difficult to visualize without assistance.

👳‍♂️Using a mirror helps clients monitor lesions for healing and recurrence.

⚠️Avoiding tight clothing and prolonged sexual abstinence are also important, but not as directly helpful for self-assessment.

📖Self-awareness improves management and early detection of outbreaks.

📌Core message

Self-assessment using a mirror helps manage genital herpes lesions.

WB NR325.NR330 Exam-2

No.

1 :
The nurse plans discharge education for a client with acute hepatitis A. What statement should the nurse plan to include in the discharge instructions?

2 :
The nurse is planning education for the caregiver of a client with Alzheimer's disease about how to maintain safety in the home. What information should the nurse plan to include in the teaching?

3 :
The nurse assesses a client with suspected meningitis. What finding should cause the nurse to suspect the client of having increased intracranial pressure?

4 :
A nurse is caring for a client with a basilar skull fracture with a cerebrospinal fluid leak following a motor vehicle accident. Which finding should be reported immediately?

5 :
The nurse interviews a client with erectile dysfunction requesting medication. What question should the nurse ask to identify contraindications?

6 :
A nurse is caring for a client with a spinal cord injury whose blood pressure is 250/130 mm Hg. The client is flushed and diaphoretic. What action should the nurse take first?

7 :
An oncology nurse is caring for a client starting chemotherapy for terminal breast cancer. Which response by the nurse is most appropriate?

8 :
A nurse assessing a client with suspected cholecystitis should expect which clinical finding?

9 :
Which statement by a client with cirrhosis indicates a need for additional education to prevent hepatic encephalopathy?

10 :
Discharge teaching after transurethral resection of the prostate: which statement indicates a need for additional teaching?

WB NR325.NR330 Exam-2

No.

1 : The nurse plans discharge education for a client with acute hepatitis A. What statement should the nurse plan to include in the discharge instructions?

2 : The nurse is planning education for the caregiver of a client with Alzheimer's disease about how to maintain safety in the home. What information should the nurse plan to include in the teaching?

3 : The nurse assesses a client with suspected meningitis. What finding should cause the nurse to suspect the client of having increased intracranial pressure?

4 : A nurse is caring for a client with a basilar skull fracture with a cerebrospinal fluid leak following a motor vehicle accident. Which finding should be reported immediately?

5 : The nurse interviews a client with erectile dysfunction requesting medication. What question should the nurse ask to identify contraindications?

6 : A nurse is caring for a client with a spinal cord injury whose blood pressure is 250/130 mm Hg. The client is flushed and diaphoretic. What action should the nurse take first?

7 : An oncology nurse is caring for a client starting chemotherapy for terminal breast cancer. Which response by the nurse is most appropriate?

8 : A nurse assessing a client with suspected cholecystitis should expect which clinical finding?

9 : Which statement by a client with cirrhosis indicates a need for additional education to prevent hepatic encephalopathy?

10 : Discharge teaching after transurethral resection of the prostate: which statement indicates a need for additional teaching?

1 :
The nurse plans discharge education for a client with acute hepatitis A. What statement should the nurse plan to include in the discharge instructions?

2 :
The nurse is planning education for the caregiver of a client with Alzheimer's disease about how to maintain safety in the home. What information should the nurse plan to include in the teaching?

3 :
The nurse assesses a client with suspected meningitis. What finding should cause the nurse to suspect the client of having increased intracranial pressure?

4 :
A nurse is caring for a client with a basilar skull fracture with a cerebrospinal fluid leak following a motor vehicle accident. Which finding should be reported immediately?

5 :
The nurse interviews a client with erectile dysfunction requesting medication. What question should the nurse ask to identify contraindications?

6 :
A nurse is caring for a client with a spinal cord injury whose blood pressure is 250/130 mm Hg. The client is flushed and diaphoretic. What action should the nurse take first?

7 :
An oncology nurse is caring for a client starting chemotherapy for terminal breast cancer. Which response by the nurse is most appropriate?

8 :
A nurse assessing a client with suspected cholecystitis should expect which clinical finding?

9 :
Which statement by a client with cirrhosis indicates a need for additional education to prevent hepatic encephalopathy?

10 :
Discharge teaching after transurethral resection of the prostate: which statement indicates a need for additional teaching?