Nursing Process Test Bank

Nursing Process Test Bank Related

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In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?

  • A. Positive family history
  • B. Infectious agents or toxins
  • C. Acute or chronic blood loss
  • D. Inadequate dietary intake
Correct Answer: A

Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition.

Summary of why the other choices are incorrect:
B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia.
C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia.
D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.

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At the present time, the best treatment for cancer is complete __________ before metastasis occurs:

  • A. Chemotherapy
  • B. Radiation
  • C. Surgical removal
  • D. All of the above
Correct Answer: C

Rationale: The correct answer is C: Surgical removal. Surgical removal of the cancerous tumor is the best treatment before metastasis because it physically removes the cancer cells. Chemotherapy and radiation are used to treat cancer after it has spread, not as the primary treatment. Choice D is incorrect because not all types of cancer can be effectively treated with all three options.

A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?

  • A. Make sure he drinks 8 glasses of water a day.
  • B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
  • C. Look for signs of hyperchloremia
  • D. Observe for neurologic changes
Correct Answer: B

Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications.

A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances.
C: Hyperchloremia is not a common concern in this scenario based on the given lab values.
D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.

The nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and:

  • A. Folic acid
  • B. Potassium
  • C. Vitamin D
  • D. Iron
Correct Answer: C

Rationale: The correct answer is C: Vitamin D. In hypoparathyroidism, there is a deficiency of parathyroid hormone leading to low calcium levels. Vitamin D helps in the absorption of calcium from the intestines, thus aiding in maintaining normal calcium levels. It is often prescribed along with calcium supplements to support bone health and prevent complications. Folic acid (A) is not directly related to the treatment of hypoparathyroidism. Potassium (B) is not typically prescribed for this condition and can be harmful in high levels. Iron (D) is not directly involved in calcium metabolism and is not part of the standard treatment regimen for hypoparathyroidism.

Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?

  • A. Increased urine output
  • B. Dyspnea on exertion
  • C. Swollen joints
  • D. Nausea and vomiting
Correct Answer: B

Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.

The nurse understands that for the parathyroid hormone to exert its effect, what must be present?

  • A. Decreased phosphate level
  • B. Functioning thyroid gland
  • C. Adequate vitamin D level
  • D. Increased calcium level
Correct Answer: D

Rationale: The correct answer is D: Increased calcium level. Parathyroid hormone functions to increase blood calcium levels. When calcium levels are low, the parathyroid gland releases PTH to stimulate the release of calcium from bones and increase calcium absorption from the intestines and kidneys. This helps to maintain normal calcium levels in the blood. Choices A, B, and C are incorrect because decreased phosphate level, functioning thyroid gland, and adequate vitamin D level are not direct requirements for the action of parathyroid hormone.

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