the nurse is caring for a client with jaundice elevated liver enzymes and an elevated serum bilirubin what color urine does the nurse expect to find
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?

Correct answer: D

Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color. Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.

2. What is the most effective strategy to assist a client in recognizing and using personal strength?

Correct answer: A

Rationale: Encouraging the client to identify their own strengths is empowering and helps build self-awareness and self-confidence. This strategy promotes autonomy and self-efficacy, enabling the client to recognize and utilize their personal strengths effectively. Option B, promoting the client's active external thinking, is vague and not directly related to recognizing personal strengths. Option C, listening to the client and providing advice as needed, focuses more on the nurse's role rather than empowering the client to recognize their strengths independently. Option D, assisting the client in maintaining an external locus of control, goes against the goal of helping the client recognize and utilize their internal strengths.

3. A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: In a situation where a patient describes a brutal assault and rape, the first priority should be to provide emotional support and create a safe and supportive environment. This helps the patient feel secure and cared for, which is crucial for their well-being at that moment. Checking with the case manager about police intervention should come after ensuring the patient's immediate emotional needs are addressed. Cleaning the patient's wounds, though important, can be secondary to providing emotional stabilization. Referring the patient to a counselor specializing in trauma is also crucial for long-term support, but the immediate focus should be on providing emotional support and stability.

4. What vitamin is important in preventing peripheral neuritis in a client with alcohol abuse?

Correct answer: B

Rationale: The correct answer is 'Fat-soluble vitamins.' Vitamin B, not Vitamin D, is crucial in preventing peripheral neuritis in individuals with alcohol abuse. Vitamin B deficiency, particularly B1 (thiamine), is commonly associated with peripheral neuritis in alcoholics. Therefore, choices A, C, and D are incorrect. Vitamin D is not directly related to peripheral neuritis, and potassium deficiency typically presents with different symptoms.

5. A client with urinary tract calculi needs to avoid which of the following foods?

Correct answer: B

Rationale: A client with urinary tract calculi needs to avoid foods high in calcium to prevent the formation of more stones. Cheese is high in calcium, so it should be avoided. Lettuce, apples, and broccoli are not typically associated with high calcium content and are safe options for individuals with urinary tract calculi. Therefore, the correct answer is cheese. Choices A, C, and D are not high in calcium and are safe for consumption by individuals with urinary tract calculi.

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