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A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
- A. Loss of hearing
- B. Paresthesia
- C. Muscle wasting
- D. Changes in vision
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia leads to Vitamin B12 deficiency, causing nerve damage and paresthesia (tingling or burning sensation). This poses a risk to the client's safety as it can affect their balance and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are potential manifestations of pernicious anemia but do not directly pose a risk to safety like paresthesia.
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A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits, the nurse notices that the client's caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver?
- A. Pursue local protective services.
- B. Consider respite care services.
- C. Take a nonprescription sleeping medication.
- D. Contact hospice services for end-of-life care.
Correct Answer: B
Rationale: The correct answer is B: Consider respite care services. Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. This is important for the caregiver's well-being and can prevent burnout. It also ensures the client receives continuous care. Pursuing local protective services (A) may escalate the situation unnecessarily. Taking nonprescription sleeping medication (C) is not a long-term solution and may have adverse effects. Contacting hospice services for end-of-life care (D) is premature and not appropriate for a client with moderate Alzheimer's disease.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins
- B. Increased blood pressure
- C. Decreased blood pressure
- D. Pitting, dependent edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration in a client with gastroenteritis results in a decrease in blood volume, leading to decreased blood pressure. When the body loses fluids through vomiting and diarrhea, there is a reduction in circulating blood volume, causing a drop in blood pressure. This can result in symptoms such as dizziness, weakness, and increased heart rate as the body tries to compensate for the reduced blood volume. Distended jugular veins (A) are more indicative of heart failure, increased blood pressure (B) can occur in conditions like hypertension or stress, and pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
- A. A client who has peritonitis reports generalized abdominal pain.
- B. A client who has angina reports substernal chest pain.
- C. A client who is postoperative reports incisional pain.
- D. A client who has pancreatitis reports pain in the left shoulder.
Correct Answer: D
Rationale: Referred pain is pain perceived at a site different from its point of origin. In the case of pancreatitis, pain is often referred to the left shoulder due to shared nerve pathways. The other choices involve pain directly related to the affected area (peritonitis, angina, postoperative incision), making them incorrect.
A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
- A. Withdraw the medication from the ampule using a needleless system.
- B. Place a paper towel around the ampule's neck to break off the top with both hands.
- C. Dispose of the top of the ampule in a sharps container.
- D. Expel air into the ampule to aspirate air bubbles.
Correct Answer: B
Rationale: The correct answer is B: Place a paper towel around the ampule's neck to break off the top with both hands. This method helps prevent injury as the paper towel provides grip and protection. Breaking the ampule's top with both hands reduces the risk of glass shards. Using a needleless system (A) is not necessary for breaking an ampule. Disposing the top in a sharps container (C) is important, but it is not the immediate action for withdrawing medication. Expelling air into the ampule (D) is unnecessary and may introduce air bubbles into the medication.
A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
- A. Joint inflammation
- B. Butterfly' rash
- C. Esophagitis
- D. Trophil
Correct Answer: A
Rationale: The correct answer is A: Joint inflammation. Systemic lupus erythematosus (SLE) commonly presents with joint inflammation due to inflammation of the synovial membrane. This can lead to pain, swelling, and stiffness in the joints. The other choices are incorrect because: B: Butterfly rash is a characteristic facial rash seen in SLE, but it is not related to joint involvement. C: Esophagitis is inflammation of the esophagus and is not a common manifestation of SLE. D: Trophil is not a recognized term in relation to SLE or its symptoms.