Nokea
A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?
- A. Mood changes
- B. Mobility challenges
- C. Shortness of breath
- D. Sleep disturbance
Correct Answer: A,B,C,D
Rationale: B12 deficiency can cause mood changes (neurological effects), mobility challenges (neuropathy), shortness of breath (anemia), and visual deficits (optic nerve damage). Sleep disturbance is not typical.
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A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?
- A. Massage over erythematous bony prominences.
- B. Implement a turning schedule every 4 hr.
- C. Keep the client's skin dry with powder.
- D. Minimize skin exposure to moisture.
- E. Use pillows to keep heels off the bed surface
Correct Answer: B,E
Rationale: Using pillows to elevate heels and minimizing moisture exposure prevent pressure ulcers and skin breakdown. Massaging erythematous areas, 4-hour turning, and powder use increase skin breakdown risk.
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 31.5
Rationale: Using the Rule of Nines, the anterior trunk is 18%, each upper limb (upper arm) is 4.5%, and each forearm is 2.25%. The calculation yields 24.75% for anterior and 6.75% for posterior, totaling 31.5% of body surface area burned.
A charge nurse is teaching a newly licensed nurse about risk factors for chronic myelogenous leukemia (CML). Which of the following information should the nurse include?
- A. Exposure to radiation
- B. Family history
- C. Another type of cancer
- D. Genetic mutation
Correct Answer: A
Rationale: Exposure to high levels of radiation is a known risk factor for CML, as seen in historical data from atomic bomb survivors. Family history and other cancers are not significant risk factors, and the Philadelphia chromosome mutation is an acquired, not inherited, genetic factor.
A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
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 a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.