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A nurse is caring for a client who has sickle cell anemia. The client asks,Why do I feel so tired and fatigued all of the time? Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have fewer red blood cells.
- C. You have an autoimmune disease.
- D. You have a low ferritin level.
Correct Answer: B
Rationale: Correct Answer: B - You have fewer red blood cells.
Rationale: In sickle cell anemia, the abnormal hemoglobin causes red blood cells to become rigid, sticky, and crescent-shaped, leading to decreased oxygen delivery. This results in anemia, leading to fatigue and tiredness. Choice A is incorrect as it does not directly relate to the pathophysiology of sickle cell anemia. Choice C is unrelated to the client's symptoms. Choice D is not specific to the underlying cause of fatigue in sickle cell anemia.
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The nurse in the emergency room is reviewing the health record of a client who is being evaluated for Graves' disease. Which of the following laboratory results is an expected finding?
- A. Decreased thyrotropin receptor antibodies
- B. Decreased free thyroxine index
- C. Decreased triiodothyronine
- D. Decreased thyroid-stimulating hormone (TSH)
Correct Answer: D
Rationale: The correct answer is D: Decreased thyroid-stimulating hormone (TSH). In Graves' disease, there is excessive production of thyroid hormones, leading to negative feedback on the pituitary gland, resulting in decreased TSH levels. This is because the elevated thyroid hormone levels signal the pituitary gland to decrease TSH production.
A: Decreased thyrotropin receptor antibodies - This is incorrect as Graves' disease is associated with increased levels of these antibodies.
B: Decreased free thyroxine index - This is incorrect as Graves' disease typically presents with elevated levels of free thyroxine.
C: Decreased triiodothyronine - This is incorrect as Graves' disease is characterized by elevated levels of triiodothyronine due to increased thyroid hormone production.
In summary, the expected finding in Graves' disease is a decreased TSH level due to the negative feedback mechanism, making option D the correct choice.
A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
- A. If a dose is missed, do not double the next dose of medication.
- B. This medication may cause dizziness upon standing.
- C. Use a dependable form of contraception while taking this medication.
- D. Do not drink alcohol while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: This medication may cause dizziness upon standing. Alprazolam is a benzodiazepine that can cause dizziness as a side effect, especially when standing up quickly. This information is important for the client to prevent falls or accidents.
A: Missing a dose should not be addressed by doubling the next dose as it can lead to overdose or adverse effects.
C: Although contraceptives might be important to discuss, it is not specifically related to the medication itself.
D: Alcohol should be avoided while taking alprazolam due to the increased risk of side effects and potential interactions, but it is not the most crucial information for the client's safety.
Which of the following is a potential dietary recommendation for a client with iron-deficiency anemia?
- A. Limit intake of iron-rich foods to prevent iron overload
- B. Focus on consuming foods high in vitamin C to enhance iron absorption
- C. Avoid foods high in iron such as leafy greens and legumes
- D. Increase intake of iron-rich foods such as red meat and spinach
Correct Answer: B,D
Rationale: The correct answers are B and D. Answer B suggests focusing on consuming foods high in vitamin C to enhance iron absorption. Vitamin C helps increase the absorption of non-heme iron found in plant-based foods, which is important for individuals with iron-deficiency anemia. Answer D recommends increasing intake of iron-rich foods such as red meat and spinach. Red meat contains heme iron, which is more easily absorbed by the body compared to non-heme iron. Therefore, including both vitamin C-rich foods and heme iron sources in the diet can help improve iron levels in individuals with iron-deficiency anemia.
Incorrect choices:
A: Limiting intake of iron-rich foods would not be advisable for someone with iron-deficiency anemia.
C: Avoiding foods high in iron would worsen the condition of iron-deficiency anemia.
E, F, G: No information provided.
According to Bowen's theoretical approach to therapy,which of the following should the nurse recognize as a concept of a functional family interaction pattern?
- A. Marital skew
- B. Sibling position
- C. Double-bind communication
- D. Pseudomutuality
Correct Answer: B
Rationale: According to Bowen's theoretical approach, sibling position is a concept of a functional family interaction pattern. This refers to the role and position each sibling holds within the family system, influencing their behavior and relationships. Understanding sibling positions helps assess family dynamics and interactions. Marital skew, double-bind communication, and pseudomutuality are not specific concepts of a functional family interaction pattern in Bowen's theory. Marital skew refers to imbalance in spousal relationships, double-bind communication involves conflicting messages, and pseudomutuality is a false sense of harmony.
A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has hired a house cleaner.
- B. The partner has placed locks at the top of the doors leading to the outside.
- C. The partner has lost 25 lb in the past 3 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 25 lb in the past 3 months indicates caregiver role strain. Weight loss can be a sign of stress and neglecting one's own needs while caring for someone with Alzheimer's. This choice reflects the physical toll caregiving can take.
A: Hiring a house cleaner (choice A) shows that the partner is seeking help and support, which is a positive coping strategy and does not necessarily indicate caregiver role strain.
B: Placing locks at the top of the doors (choice B) demonstrates safety measures for the client and does not directly indicate caregiver role strain.
D: Redirecting the client when frustrated (choice D) shows appropriate management of challenging behaviors and does not directly indicate caregiver role strain.
In summary, choice C is the best indicator of caregiver role strain as it reflects the physical impact of the caregiving responsibilities on the partner's well-being.