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The nurse is assessing a client with severe anemia. Which clinical manifestation does the nurse expect to see in this client?
- A. Bradycardia
- B. Pale, cool skin
- C. Hypertension
- D. Warm, flushed skin
Correct Answer: B
Rationale: Severe anemia starves oxygen pale, cool skin reflects shunted flow and low hemoglobin, a classic find as body compensates. Bradycardia's rare; tachycardia revs to pump more. Hypertension doesn't fit BP may drop. Warm, flushed skin suits overload, not anemia. Nurses expect pallor, tying it to blood's oxygen flop, a sign guiding transfusion or iron.
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Which does not cause genital ulceration?
- A. syphilis
- B. herpes simplex infection
- C. HIV
- D. lymphogranuloma venereum
Correct Answer: C
Rationale: HIV no direct ulcers; syphilis, herpes, LGV, chancroid carve sores. Nurses rule this chronic outlier.
A 45 year old man, BMI 35 but otherwise healthy and normotensive has an urinary albumin excretion of 30 mg in 24 hours. Which is the correct action to take?
- A. Reduce weight
- B. It can be observed over 3 months for improvement
- C. Refer him to a nephrologist
- D. Treatment is required
Correct Answer: A
Rationale: Albumin 30 microalbuminuria's dawn, weight loss curbs it; watch, refer, treat, ignore lag. Nurses nudge this chronic kidney shield.
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?
- A. Pruritis (itching)
- B. Nausea and vomiting
- C. Altered glucose metabolism
- D. Confusion
Correct Answer: B
Rationale: Nausea and vomiting top the chemo side-effect list, hitting most patients due to drugs (e.g., cisplatin, doxorubicin) irritating the gut and triggering the brain's vomiting center. It can last 24-48 hours post-dose, often needing antiemetics like ondansetron. Pruritis might occur with specific agents or reactions, but it's less universal. Glucose metabolism shifts are rare, tied to steroids or endocrine effects, not a chemo hallmark. Confusion could stem from brain mets or fatigue, not a primary effect. Nurses prep patients for this duo nausea and vomiting ensuring they know it's manageable with meds and timing, easing anxiety and boosting adherence in early oncology treatment.
In the clinical assessment of heart failure, which of the following is FALSE?
- A. Jugular venous distention, an S1 heart sound, and non-displaced apical impulse significantly increase the likelihood of the diagnosis
- B. Hypertension, CAD, and valvular disease are the most common causes
- C. Fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and edema are common symptoms
- D. Cardiomegaly on CXR is helpful in supporting the diagnosis
Correct Answer: A
Rationale: Jugular venous distention and edema suggest heart failure, but S1 (normal first sound) and non-displaced apical impulse don't increase diagnostic likelihood S3 or displaced impulse do, per clinical criteria. Common causes (HTN, CAD, valvular disease), symptoms, and cardiomegaly on CXR are true. ECG is vital. This corrects diagnostic focus in chronic HF assessment.
Spirometry is used to determine the severity of COPD and to monitor disease progression. This test measures
- A. The ratio of volume of air the patient can forcibly exhale in 1 second and forced vital capacity
- B. The ratio of residual volume when patient has fully exhaled and forced vital capacity
- C. The ratio of forced vital capacity and volume of air the patient can forcibly exhale in 6 seconds
- D. The ratio of respiratory effort and respiratory rate
Correct Answer: A
Rationale: Spirometry sizes COPD FEV1/FVC ratio, air blasted in one second versus all-out capacity, pegs obstruction's depth, tracking decline. Residual's post-exhale, not this; 6-second's off; effort-rate's vague. Nurses lean on this, staging chronic airflow's fade.