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A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
- A. Night sweats, weight loss, and diarrhea
- B. Nausea, vomiting, and anorexia
- C. Dyspnea, tachycardia, and pallor
- D. Itching, rash, and jaundice A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET H
Correct Answer: C
Rationale: Rationale:
1. Anemia results in decreased oxygen-carrying capacity, leading to tissue hypoxia.
2. Dyspnea (shortness of breath) occurs due to the body's attempt to increase oxygen intake.
3. Tachycardia (rapid heart rate) compensates for decreased oxygen delivery.
4. Pallor (pale skin) is a classic sign of decreased red blood cells in iron-deficiency anemia.
Summary:
A: Night sweats, weight loss, and diarrhea are not typical manifestations of iron-deficiency anemia.
B: Nausea, vomiting, and anorexia are non-specific symptoms and not specific to iron-deficiency anemia.
D: Itching, rash, and jaundice are not commonly associated with iron-deficiency anemia.
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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
- A. Stand as far away from the implant as possible and call for help.
- B. Pick up the implant with long-handled forceps and place it in a lead-lined container.
- C. Leave the room and notify the radiation therapy department immediately.
- D. Put the implant back in place, using forceps and a shield for self-protection, and call for help.
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice C) delays the immediate action needed to prevent unnecessary radiation exposure.
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- A. Completes a comprehensive database
- B. Identifies pertinent nursing diagnoses
- C. Intervenes based on priorities of patient care
- D. Determines whether outcomes have been achieved
Correct Answer: A
Rationale: The correct answer is A because during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This step is crucial for identifying the patient's needs and developing a holistic care plan.
Choice B is incorrect because identifying nursing diagnoses typically occurs in the second phase (diagnosis). Choice C is incorrect as intervening based on care priorities happens in the third phase (planning and implementation). Choice D is incorrect as determining outcomes achieved is part of the final phase (evaluation).
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, “I refuse to take care of that dirty old man!” Which response by the nurse is best?
- A. “The next time he tries to touch you inappropriately, lightly smack his hand and tell him no!”
- B. “His stroke has made him less inhibited. We’ll see if we can find a male assistant to help him.”
- C. “We have to take care of all patients equally, even the dirty old men.”
- D. “He didn’t mean anything by it, just ignore it.”
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the patient's behavior is likely due to the stroke affecting his inhibitions. Finding a male assistant respects both the patient's dignity and the nursing assistant's comfort. Choice A is inappropriate as physical violence is never an acceptable response. Choice C lacks empathy and understanding of the situation. Choice D minimizes the seriousness of the behavior and fails to address the issue. B is the best option for promoting a safe and respectful environment for both the patient and staff.
The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?
- A. antidiuretic hormone (ADH).
- B. follicle-stimulating hormone (FSH).
- C. thyroid-stimulating hormone (TSH).
- D. luteinizing hormone (LH).
Correct Answer: A
Rationale: The correct answer is A: antidiuretic hormone (ADH). In diabetes insipidus, there is a deficiency of ADH, which regulates water balance by reducing urine output. Without ADH, excessive urination and thirst occur. FSH, TSH, and LH are not related to water balance regulation. FSH and LH are involved in reproductive functions, while TSH regulates thyroid hormone production. Therefore, the nurse should focus on educating the client about the importance of ADH in managing diabetes insipidus.