Nokea
The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit?
- A. Excessive consumption of coffee or tea
- B. Elimination of iron by the body
- C. Decrease in the total body iron stores with age
- D. Blood loss from the gastrointestinal or genitourinary tract
Correct Answer: D
Rationale: If an older adult is anemic, blood loss from the gastrointestinal or genitourinary tract is suspected. This is because iron-deficiency anemia is unusual in older adults as the body does not eliminate excessive iron, causing total body iron stores to increase with age. Excessive consumption of coffee or tea is not a causative factor for anemia in older adults.
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The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, 'Why do I have to drink so much?' What is the best response by the nurse?
- A. We don't want you to get dehydrated.
- B. It helps adequately hydrate you and ensures a sufficient urine production.
- C. It will help your heart beat regularly and effectively.
- D. It will help restrict blood circulation.
Correct Answer: B
Rationale: The client should be advised to drink 3 quarts (or liters) per day. Adequate hydration promotes venous return and ensures sufficient urine production. Informing the client that the healthcare team does not want them to get dehydrated does not address the rationale that the client requires. Fluid hydration will not help the heart beat regularly or more effectively and it will not help to restrict blood circulation.
The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is mostly likely to be receiving treatment for sickle cell crisis?
- A. A 29-year-old Caucasian male
- B. A 19-year-old male of African descent
- C. A 24-year-old Native American/First Nations female
- D. A 36-year-old Eastern European female
Correct Answer: B
Rationale: Sickle cell disease is a common genetic disorder found primarily in clients of African descent but also in people from Mediterranean and Middle Eastern countries. It is unlikely that a Caucasian male, Native American/First Nations female, or eastern European female will be affected by this disease.
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?
- A. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate.
- B. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow.
- C. This type of exercise increases arterial circulation as it returns to the heart.
- D. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
Correct Answer: D
Rationale: Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.
A client diagnosed with polycythemia vera has come into the clinic because they have developed a night-time cough, fatigue, and shortness of breath. From these clinical manifestations, what complication would the nurse suspect in this client?
- A. Stroke
- B. Tissue infarction
- C. Congestive heart failure
- D. Pulmonary embolus
Correct Answer: C
Rationale: The symptoms exhibited by this client are indicative of heart failure. Complications of polycythemia vera include hypertension, heart failure, stroke, tissue and organ infarction, and hemorrhage.
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?
- A. Do not take medication with orange juice because it will delay absorption of the iron.
- B. Iron may cause indigestion and should be taken with an antacid such as Mylanta.
- C. Dilute the liquid preparation with another liquid such as juice and drink with a straw.
- D. Discontinue the use of iron if your stool turns black.
Correct Answer: C
Rationale: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.