Nokea
A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
- A. Hyperactivity in the evening hours
- B. Weight gain
- C. Paresthesia of hands and feet
- D. Diarrhea stools
Correct Answer: C
Rationale: Paresthesia of hands and feet indicates B12 deficiency due to noncompliance with injections, as B12 is needed for nerve function. Hyperactivity (A), weight gain (B), and diarrhea (D) are not specific to B12 deficiency.
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A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:
- A. Obtain vital signs
- B. Connect the client to the cardiac monitor
- C. Ask the client if he is still having chest pain
- D. Complete the history profile
Correct Answer: B
Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.
The nurse is caring for a client with a history of schizophrenia. The nurse should expect the client to have:
- A. Hallucinations
- B. Memory loss
- C. Tremors
- D. Joint pain
Correct Answer: A
Rationale: Schizophrenia is characterized by hallucinations, delusions, and disorganized thinking, with hallucinations being a common symptom.
Before completing a nursing diagnosis, the nurse must first:
- A. Write goals and objectives
- B. Perform an assessment
- C. Plan interventions
- D. Perform evaluation
Correct Answer: B
Rationale: Assessment is the first step of nursing process.
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
- A. Cullen's sign
- B. Rebound tenderness
- C. Murphy's sign
- D. Turner's sign
Correct Answer: C
Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
During burn therapy, morphine is primarily administered IV for pain management because this route:
- A. Delays absorption to provide continuous pain relief
- B. Facilitates absorption because absorption from muscles is not dependable
- C. Allows for discontinuance of the medication if respiratory depression develops
- D. Avoids causing additional pain from IM injections
Correct Answer: B
Rationale: IM injections are unreliable in burn patients due to fluid shifts into interstitial spaces, leading to poor absorption. IV administration ensures dependable absorption and effective pain relief.