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Signs of clotting and bleeding concurrently indicate
- A. Hemophilia.
- B. Multiple myeloma.
- C. Disseminated intravascular coagulation.
- D. Polycythemia vera.
Correct Answer: C
Rationale: DIC involves both clotting and bleeding due to widespread activation of the coagulation system.
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What does using random weights help to prevent when weighing a client diagnosed with binge eating?
- A. Dehydration
- B. Lying about weight
- C. Water loading
- D. Denial of weight loss
Correct Answer: B
Rationale: Random weights reduce opportunities for clients to manipulate or lie about their actual weight.
Mary has been dieting and exercising daily. Her weight is well below the recommended minimum for her height. Assessment for Mary would include looking for
- A. Ecchymosis and extraocular movements.
- B. Temporal wasting and irregular heart rhythm.
- C. Peripheral edema and rales.
- D. Periorbital edema and chorea.
Correct Answer: B
Rationale: Extreme weight loss can lead to temporal wasting and cardiac irregularities.
What term is used to describe a decreased effect of a substance following repeated exposure?
- A. Relapse
- B. Tolerance
- C. Abstinence
- D. Withdrawal.
Correct Answer: B
Rationale: Tolerance develops when repeated exposure to a substance diminishes its effects, requiring higher doses to achieve the same impact.
The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
- A. Evaluate chest expansion.
- B. Check pupillary response to light.
- C. Assess the capillary refill.
- D. Check the client's response to questions about place and time.
Correct Answer: A
Rationale: The correct answer is A: Evaluate chest expansion. This is the priority action because it assesses the client's airway and breathing, which are critical for survival. Checking chest expansion helps to identify any potential respiratory compromise or underlying lung injuries. Assessing pupillary response (B) and capillary refill (C) are important, but they are secondary to ensuring adequate oxygenation. Checking the client's orientation to place and time (D) is important for neurological assessment but is not as critical as assessing airway and breathing in this scenario.
The patient asks you what the clip on his finger is for. The best response is
- A. This is a cardiac monitor that alerts us to any arrhythmia that you might experience during the night.
- B. This measures your temperature.
- C. This is pulse oximetry and is used to give us an idea of how much oxygen is in your blood.
- D. This tells us the number of red blood cells you have. These cells provide oxygen throughout your body.
Correct Answer: C
Rationale: Pulse oximetry measures oxygen saturation in the blood.