Nokea
The presence of anemia is characterized by a/an:
- A. Increase of red blood cells
- B. Increased hemoglobin
- C. Decrease in the concentration of red blood
- D. Decreased blood count cells
Correct Answer: C
Rationale: Anemia is a condition characterized by a decrease in the concentration of red blood cells in the blood. This can result from various factors such as decreased production of red blood cells, increased destruction of red blood cells, or blood loss. Hemoglobin levels are often used to diagnose anemia, but the key feature of anemia is the decrease in the number of red blood cells, leading to reduced oxygen-carrying capacity in the blood. This in turn can lead to symptoms such as fatigue, weakness, and shortness of breath.
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The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
- A. Duodenal ulcer
- B. Weight gain
- C. Hemorrhoids
- D. Polyps
Correct Answer: D
Rationale: The presence of polyps in the colon is a significant risk factor for developing colorectal cancer. Polyps are abnormal growths in the inner lining of the colon or rectum that can potentially become cancerous over time if left untreated. Therefore, if a client has a history of polyps, the nurse may suspect the possibility of colorectal cancer and should closely monitor the client for any signs or symptoms. While the other conditions listed may sometimes be associated with colorectal cancer, having a history of polyps is the most concerning in this context.
The home health nurse asks a child's mother many questions as part of the assessment. The mother answers many questions, then stops and says, "I don't know why you ask me all this. Who gets to know this information?" The nurse should take which action?
- A. Determine why the mother is so suspicious.
- B. Determine what the mother does not want to tell.
- C. Explain who will have access to the information.
- D. Explain that everything is confidential and that no one else will know what is said.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to explain who will have access to the information. This can help build trust with the child's mother and alleviate any concerns she may have about the confidentiality of the information shared during the assessment. By explaining clearly who will have access to the information and how it will be used, the nurse can address the mother's concerns and ensure that she feels comfortable sharing necessary information for the child's care. This open communication is essential in building a supportive and trusting relationship between the nurse and the child's mother.
Which of the following is most likely associated with a cerebrovascular accident (CVA) resulting from congenital heart disease?
- A. Polycythemia
- B. Cardiomyopathy
- C. Endocarditis
- D. Low blood pressure
Correct Answer: A
Rationale: Polycythemia, which is an abnormally elevated level of red blood cells in the blood, is commonly associated with congenital heart disease. In cases where there is a congenital heart defect that causes reduced oxygen levels in the blood, the body compensates by producing more red blood cells to try to improve oxygen delivery. This increased red blood cell production can lead to polycythemia. In turn, polycythemia can increase the risk of thrombosis, which is a known risk factor for cerebrovascular accidents (CVAs) or strokes. Therefore, polycythemia is most likely associated with a CVA resulting from congenital heart disease.
Of the following, the MOST likely cause of constipation is
- A. hypothyroidism
- B. Hirschsprung disease
- C. functional constipation
- D. celiac disease
Correct Answer: C
Rationale: Functional constipation is the most common cause of constipation in children, often due to diet or behavioral factors.
The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the ff. is the best evidence that the teaching has been effective?
- A. The patient states that he will be careful to avoid injury.
- B. The patient can list signs and symptoms of bleeding.
- C. The patient uses an electric razor instead of his safety razor.
- D. The patient states when he should call the doctor.
Correct Answer: C
Rationale: The best evidence that the teaching has been effective is when the patient uses an electric razor instead of his safety razor. This action demonstrates understanding and application of the teaching to prevent bleeding in a practical way. By choosing the electric razor, the patient is actively taking steps to minimize the risk of injury and bleeding due to thrombocytopenia. This concrete behavior indicates that the patient has internalized the instructions provided by the nurse and is implementing them to protect his health.