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 caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
- A. Obtain a venous duplex ultrasound.
- B. Obtain impedance plethysmography.
- C. Monitor Homan's sign
- D. Apply cold therapy to the affected leg
Correct Answer: A
Rationale: Symptoms suggest deep vein thrombosis (DVT), and a venous duplex ultrasound is the standard diagnostic test to confirm a thrombus. Other options are less reliable or inappropriate.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
- A. "I need something for the pain in my eye. I can't stand it."
- B. "It's hard to see with a patch on one eye. I'm afraid of falling"
- C. "My eye really itches, but I'm trying not to rub it."
- D. "The bright light in this room is really bothering me."
Correct Answer: A
Rationale: Severe pain after cataract surgery is unusual and could indicate complications like increased intraocular pressure or infection, requiring immediate reporting. Other comments reflect common post-surgical experiences.
A nurse is providing dietary teaching to a client who has a new onset of vitamin B12 deficiency. Which of the following foods should the nurse encourage the client to include in their diet?(Select All that Apply)
- A. Steak
- B. Low fat milk
- C. Grilled salmon
- D. Green leafy vegetables
- E. Scrambled eggs
Correct Answer: A,B,C,E
Rationale: Steak, milk, salmon, and eggs are high in vitamin B12, suitable for addressing deficiency. Green leafy vegetables are not significant sources of B12, which is primarily found in animal products.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- A. Heart rate
- B. Weight
- C. Urine output
- D. BP
Correct Answer: A
Rationale: A decrease in heart rate indicates improved cardiac output and reduced tachycardia, suggesting adequate fluid replacement. Weight may increase, urine output should increase, and BP stabilizes but is less direct an indicator.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. A piece of healthy skin will be removed from an unburned area and grafted over the burned area.
- B. Large incisions will be made in the eschar to improve circulation.
- C. The procedure involves placing the client into a shower and removing the dead tissue.
- D. Dead tour will be non-surgically removed.
Correct Answer: B
Rationale: An escharotomy involves incisions through the eschar to relieve pressure and improve blood flow, preventing complications like compartment syndrome. Other options describe different procedures.