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In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site?
- A. Biliary system.
- B. Gastrointestinal tract.
- C. Brain and meninges.
- D. Pulmonary system.
Correct Answer: A
Rationale: Thrombocytopenia in leukemia increases bleeding risk in the gastrointestinal tract, brain/meninges, and pulmonary system due to mucosal surfaces and vascularity. The biliary system is not a common site for bleeding.
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The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors?
- A. The tremors are probably psychological and can be controlled at will.
- B. The tremors sometimes disappear with purposeful and voluntary movements.
- C. The tremors disappear when the client's attention is diverted by some activity.
- D. There is no explanation for the observation; it is probably a chance occurrence.
Correct Answer: B
Rationale: In Parkinson's disease, resting tremors often decrease or disappear during purposeful movements, such as unbuttoning a shirt. This is a characteristic feature, not psychological, distraction-related, or random.
The client with diabetes mellitus says, 'If I could just avoid what you call carbohydrates in my diet, I guess I would be okay.' The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following?
- A. Carbohydrates only.
- B. Fats and carbohydrates only.
- C. Protein and carbohydrates only.
- D. Proteins, fats, and carbohydrates.
Correct Answer: D
Rationale: Diabetes affects the metabolism of carbohydrates, proteins, and fats due to insulin's role in regulating all three macronutrients.
A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select all that apply.
- A. Witness the client signing the consent form.
- B. Evaluate that the client understands the procedure.
- C. Explain the risks of the procedure to the client.
- D. Verify that the client is signing the consent form of his own free will.
- E. Determine that the client understands postprocedure care.
Correct Answer: A,B,D,E
Rationale: The nurse's role in obtaining consent includes witnessing the signature, ensuring the client understands the procedure and postprocedure care, and verifying voluntary consent. Explaining risks is typically the physician's responsibility.
A nurse is assessing a client with bone cancer pain. Which of the following components of a thorough pain assessment is most significant for this client?
- A. Intensity.
- B. Cause.
- C. Aggravating factors.
- D. Location.
Correct Answer: A
Rationale: Pain intensity is the most significant component in assessing bone cancer pain, as it guides the urgency and type of pain management interventions needed.
Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?
- A. Pulse rate less than 60 bpm.
- B. Respiratory rate of 4 breaths/minute.
- C. Pupils unequally dilated.
- D. Systolic blood pressure less than 90 mm Hg.
Correct Answer: D
Rationale: A 15% blood loss can cause hypovolemic shock, with early signs including hypotension (systolic BP <90 mm Hg) due to reduced circulating volume. Bradycardia, low respiratory rate, and unequal pupils are not typical findings.