Nokea
The nurse is assessing a client who has a hemoglobin level of 5 g/dL (50 g/L). Which of the following findings would the nurse expect to obtain? Select all that apply.
- A. Coarse crackles
- B. Dyspnea
- C. Pallor
- D. Respiratory depression
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Severe anemia (5 g/dL) reduces oxygen-carrying capacity, causing dyspnea (B), pallor (C), and tachycardia (E) as compensatory mechanisms. Crackles (A) suggest fluid overload, and respiratory depression (D) is unrelated.
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The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?
- A. Ask the client to place the backs of the hands against each other to provide hyperextension of the wrist while the elbows remain flexed
- B. Perform the Romberg test by asking the client to stand with the eyes closed and the feet together
- C. Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
Correct Answer: C
Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (A) is unrelated to hypocalcemia, and the Romberg test (B) assesses balance, not relevant to this scenario.
A child with a high level of school absenteeism is diagnosed with separation anxiety disorder. The school nurse should remind the child’s parent to take what action?
- A. Allow the child to stay home when the child seems anxious
- B. Call the teacher to get the child’s schoolwork to do at home
- C. Have the child attend school, starting with a few hours a day
- D. Sit with the child in the classroom whenever possible
Correct Answer: C
Rationale: Gradual exposure to school, starting with partial attendance (C), helps desensitize the child to separation anxiety. Staying home (A) reinforces avoidance, schoolwork at home (B) delays reintegration, and parental presence (D) hinders independence.
Which of the following activities is most suitable for a 10-year old with asthma?
- A. Soccer
- B. Swimming
- C. Basketball
- D. Constructing model cars
Correct Answer: B
Rationale: Swimming is ideal for children with asthma, as the humid environment reduces airway irritation, unlike high-exertion sports like soccer or basketball.
A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?
- A. Blurred vision
- B. Dark-colored urine
- C. Difficulty hearing
- D. Yellow skin
Correct Answer: A
Rationale: Ethambutol can cause optic neuritis, leading to blurred vision (A), a serious side effect requiring immediate reporting. Dark urine (B), hearing loss (C), and jaundice (D) are associated with other TB drugs (e.g., rifampin, isoniazid).
During the evaluation phase for a client, the nurse should focus on
- A. All finding of physical and psychosocial stressors of the client and in the family
- B. The client's status, progress toward goal achievement, and ongoing re-evaluation
- C. Setting short and long-term goals to insure continuity of care from hospital to home
- D. Select interventions that are measurable and achievable within selected timeframes
Correct Answer: B
Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.