Nokea
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
- A. Scalp
- B. Chest
- C. Axillae
- D. Conjunctivae
Correct Answer: D
Rationale: When assessing for pallor in a patient with anemia, the nurse should specifically look at the conjunctivae (the membranes that cover the white part of the eyes). In individuals with anemia, the lack of red blood cells can result in paleness in the conjunctivae, which can be observed as a pale or whitish color. This area is especially useful for assessing pallor in individuals with darker skin tones, such as African Americans, where pallor may be less noticeable on other areas of the body.
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a woman who is pregnant is undergoing an amniocentesis. during the test, elevated levels of AFP are found. this indicate to which of the following conditions :
- A. CP
- B. spina bifida
- C. down syndrome
- D. hydrocephalus
Correct Answer: B
Rationale: Elevated levels of AFP (alpha-fetoprotein) in the amniotic fluid during an amniocentesis often indicate neural tube defects, such as spina bifida. Spina bifida is a condition where the spinal cord does not develop properly, leading to a range of possible issues depending on the severity of the defect. In this case, the elevated AFP levels point towards a higher likelihood of spina bifida rather than other conditions like CP (cerebral palsy), Down syndrome, or hydrocephalus.
You would not find which of the following assessments in a patient with severe anemia?
- A. Pallor
- B. Fatigue
- C. Cold sensitivity
- D. Dyspnea only on exertion
Correct Answer: C
Rationale: Severe anemia is associated with a reduced number of red blood cells, leading to decreased oxygen delivery to the body's tissues. Therefore, symptoms commonly seen in patients with severe anemia include pallor (pale skin), fatigue (due to decreased energy levels), and dyspnea (shortness of breath) especially on exertion (due to the heart working harder to compensate for the reduced oxygen-carrying capacity of the blood). Cold sensitivity is not a typical symptom of anemia and is not directly related to the reduced oxygen-carrying capacity of the blood.
Pulmonary edema is characterized by:
- A. Elevated left ventricular and-diastolic
- B. Increased hydrostatic pressure
- C. All of the above alterations
- D. A rise in pulmonary venous pressure
Correct Answer: C
Rationale: Pulmonary edema is characterized by increased hydrostatic pressure in the pulmonary capillaries and a rise in pulmonary venous pressure, which leads to fluid leaking out of the pulmonary capillaries and into the alveoli. This results in elevated left ventricular end-diastolic pressure, which is a key characteristic of pulmonary edema. Therefore, all of the above alterations (increased hydrostatic pressure, a rise in pulmonary venous pressure, and elevated left ventricular end-diastolic pressure) are seen in pulmonary edema.
Choose the condition that exhibits blood values with a low pH and a high PCO :
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metaboliâ‚‚c alkalosis
Correct Answer: A
Rationale: Respiratory acidosis is a condition characterized by elevated levels of carbon dioxide (high PCOâ‚‚) and decreased blood pH (low pH) due to inadequate ventilation leading to the accumulation of carbon dioxide in the body. The excess carbon dioxide reacts with water in the blood to form carbonic acid, resulting in a decrease in pH. This is in contrast to metabolic acidosis, which is characterized by an accumulation of acids other than carbon dioxide, leading to a low blood pH. Respiratory alkalosis would present with a low PCOâ‚‚ and high pH, while metabolic alkalosis features a high pH and elevated bicarbonate levels due to non-respiratory causes.
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
- A. slap the chest wall gently
- B. use vibration techniques to move secretions from affected lung areas during the inspiration phase
- C. perform CPT at least two hours after meals
- D. plan apical drainage at the beginning of the CPT session
Correct Answer: C
Rationale: Performing chest physiotherapy (CPT) at least two hours after meals is important to prevent potential risks such as vomiting and aspiration. This timing allows for better tolerance of the procedure and decreases the likelihood of complications. By waiting at least two hours after meals, the nurse ensures that the patient's stomach is not full, reducing the risk of regurgitation during the chest physiotherapy session. This practice promotes the safety and well-being of the patient while undergoing this treatment.