The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient waves to the nurse as she enters the room. How should the nurse interpret this?
a. As an attempt to get the nurse's attention
b. As asterixis
c. As an indication of respiratory obstruction from varices
d. As spasticity
ANS: B
Asterixis is the "flapping tremor" seen as the patient deteriorates into ammonia intoxication or hepatic encephalopathy.
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A 63-year-old patient on the medical floor has a diagnosis of adrenal hyperfunction (Cushing's syndrome). She will probably have to adhere to a diet that contains
a. less sodium. b. more calories. c. less potassium. d. more carbohydrates.
The nurse is administering a tuberculin skin test for a client. What is the nurse's understanding of the hypersensitivity response associated with this test? Select all that apply.
A) The test causes a release of lymphokines, which attract macrophages. B) Macrophages release lysozymes, resulting in local tissue damage. C) The antigen-presenting cell encounters a cytotoxic T-cell. D) Antigens invade the body and bind to antibodies in circulation. E) Antigen-antibody complexes activate complement.
A competent older adult patient has a living will stating that resuscitation and heroic life support measures are to be avoided. The family members are not supportive of this directive. Which action by the nurse is the most appropriate?
1. Place the document on the chart. 2. Contact the Social Services department. 3. Notify the hospital attorney. 4. Explain to the patient that the conflict could invalidate the document.
A patient who fears serious heart disease was referred to the mental health center by a cardiologist after extensive diagnostic evaluation showed no physical illness. The patient says, "I have tightness in my chest and my heart misses beats
I'm frequently absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Antisocial personality disorder c. Simple somatic symptom disorder d. Prominent health anxiety (hypochondriasis)