While assessing a patient with acute hepatic dysfunction, the nurse notes the presence of veins over the patient's abdominal region. This finding would be consistent with which of the following?
1. esophageal varices
2. hypernatremia
3. elevated ammonia level
4. portal vein obstruction
4
Rationale: Caput medusa or visible veins over the abdomen and umbilical region are caused by congestion and dilation of superficial abdominal veins associated with portal vein obstruction. These veins are not indicative of esophageal varices. Engorged veins are not associated with hypernatremia or elevated ammonia levels.
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Anxiety and fear may require that the nurse
A) repeat instructions more than once. B) speak in a louder voice than normal. C) give handwritten instructions, rather than oral. D) All of the above are correct.
A 35-year-old woman is being assessed related to suspected battering. In interviewing this patient, it is important for the nurse to keep in mind that: (Select all that apply.)
a. the nurse's demeanor should be one of concern and caring. b. professional terminology should be used and taught to the patient. c. all noted injuries should be thoroughly and explicitly documented. d. police personnel or other witnesses should be present during the interview. e. teaching assertiveness and coping skills is a priority to reduce victimization. f. abuse survivors may conceal their injuries to reduce future assaults.
An elderly client tells the nurse that she is having difficulty sleeping because she is up all night voiding since she has been told to drink eight glasses of water every day. Which of the following should the nurse assess in this client?
a. Volume of urine output with each episode of voiding b. Ambulatory status c. Appetite d. Time in which the fluids are being ingested
Which of the following factors has the greatest impact on body temperature regulation?
A) Newborns are homeothermic. B) Normal temperature of children under 3 years old is 99°F. C) Normal temperature of adults is 98.6°F. D) Older adults have decreased thermoregulation.