Nokea
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue).
Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.
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Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: The correct answer is A: Provide positive feedback when he uses the word correctly. In individuals with expressive aphasia, positive reinforcement helps improve communication skills. Praising Mr. Reyea when he uses words correctly encourages continued effort and boosts confidence. This approach motivates him to communicate more despite his challenges.
Summary of other choices:
B: Waiting indefinitely for Mr. Reyea to verbally state needs is not practical and may lead to frustration.
C: Suggesting permanent help at home assumes the disability cannot improve, which is not necessarily true for expressive aphasia.
D: Helping the family to accept Mr. Reyea's inability to communicate verbally may hinder his progress and limit his social interactions.
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
- A. Level of central vision
- B. Pupil responses
- C. External eye appearance
- D. Eye movements
Correct Answer: B
Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health.
A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment.
C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses.
D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.
Which of the following is classified as subjective data in a nursing assessment?
- A. Heart rate of 90 beats per minute
- B. Client states, 'I feel nauseated.'
- C. Blood pressure of 130/80 mmHg
- D. Skin appears flushed
Correct Answer: B
Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly.
A, C, and D are incorrect:
A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed.
C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed.
D: Skin appears flushed is an objective observation that can be directly seen.
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, 'I am very nervous and scared to have surgery.' What client outcome is the priority?
- A. Evaluate the need for antibiotics.
- B. Resolve the client’s anxiety.
- C. Provide preoperative education.
- D. Prepare the client for surgery.
Correct Answer: B
Rationale: The correct answer is B: Resolve the client’s anxiety. Addressing the client's anxiety is the priority because it can impact their overall surgical experience, recovery, and outcomes. Resolving anxiety can improve the client's emotional well-being, enhance cooperation during surgery, and reduce postoperative complications related to stress. Providing emotional support and reassurance should be the initial focus to help the client feel more comfortable and confident about the upcoming surgery. The other choices are not the priority in this situation: A) Evaluating the need for antibiotics can be addressed later in the preoperative process, C) Providing preoperative education is important but not the immediate priority over addressing anxiety, and D) Preparing the client for surgery includes various components, but emotional well-being should be addressed first.
The nurse is teaching a patient newly diagnosed with AIDS about complications of the disease. Which of the following is the most common opportunistic infection in AIDS?
- A. Pneumocystis carinii pneumonia
- B. Toxoplasmosis
- C. Candidiasis
- D. Mycoplasma pneumoniae
Correct Answer: A
Rationale: The correct answer is A: Pneumocystis carinii pneumonia (PCP). PCP is the most common opportunistic infection in AIDS due to the weakened immune system, making patients vulnerable to this fungal infection. PCP is a leading cause of morbidity and mortality in AIDS patients. Toxoplasmosis (B) is also common but not as prevalent as PCP in AIDS. Candidiasis (C) is a common fungal infection but not the most common in AIDS. Mycoplasma pneumoniae (D) is a bacterial infection and not typically considered an opportunistic infection in AIDS.