Nokea
A client is admitted with suspected pernicious anemia. Which findings support the diagnosis of pernicious anemia?
- A. The client complains of feeling tired and listless.
- B. The client has waxy, pale skin.
- C. The client exhibits loss of coordination and position sense.
- D. The client has a rapid pulse rate and a detectable heart murmur.
Correct Answer: C
Rationale: Loss of coordination and position sense are neurological symptoms due to vitamin B12 deficiency in pernicious anemia.
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An operating room nurse just received a client scheduled for a laparoscopic cholecystectomy, but discovers the consent form has not been signed. What is the most appropriate action?
- A. bring the client a new consent form and have him sign it right away
- B. call the surgeon and ask how she would like to proceed
- C. inform the nursing manager there is no signed consent form
- D. ask the unit manager if the surgery can be rescheduled for later in the day
Correct Answer: B
Rationale: Missing consent requires notifying the surgeon to ensure the client is informed and consents before proceeding, adhering to legal and ethical standards.
A labor and delivery nurse is caring for a client in active labor. The fetal monitor shows late decelerations. The nurse should first
- A. place the client in high-Fowler's position in preparation to push.
- B. place the client in left lateral recumbent position.
- C. increase the rate of IV Pitocin.
- D. call the physician and report fetal distress.
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The left lateral position improves placental perfusion, addressing the immediate cause.
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Correct Answer: D
Rationale: A pulsatile mass in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding aorta.
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glascow coma scale.
Correct Answer: A
Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.
The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
- A. Nephritis
- B. Cardiomegaly
- C. Desquamation
- D. Meningitis
Correct Answer: A
Rationale: Nephritis is the major complication of SLE due to immune complex deposition in the kidneys, leading to lupus nephritis, which can cause renal failure if untreated.