Nokea
What condition should the nurse assess a client diagnosed with pernicious anemia for? Select all that apply.
- A. Weakness
- B. Constipation
- C. Shortness of breath
- D. Dusky lips and gums
- E. Smooth, sore, red tongue
Correct Answer: A,E
Rationale: Classic clinical indicators of pernicious anemia include weakness; mild diarrhea; and a smooth, sore, red tongue. The client may also have neurological findings, such as paresthesias, confusion, and difficulty with balance. Constipation is not a common finding with pernicious anemia. Pernicious anemia does not affect tissue oxygenation, so the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.
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The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for:
- A. Anesthesia below the level of the injury.
- B. Tingling in the fingers.
- C. Pain below the site of the injury.
- D. Loss of position and vibratory sense.
Correct Answer: A,D
Rationale: Spinal cord injury often causes anesthesia (loss of sensation) and loss of position/vibratory sense below the injury level. Tingling or pain below the injury is less likely due to disrupted nerve pathways.
Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
- A. 1 to 2 mL/kg/hour.
- B. 3 to 5 mL/kg/hour.
- C. 6 to 8 mL/kg/hour.
- D. 10 to 12 mL/kg/hour.
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
- A. Notify the physician.
- B. Administer a sedative.
- C. Try to elicit a positive Homan's sign.
- D. Increase the flow rate of intravenous fluids.
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.
Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply.
- A. Warm the fingers or toes by using an electric heating pad
- B. Wear warm socks or gloves when exposed to cold temperatures
- C. Check the temperature of bath water before entering
- D. Use a hot water bottle to warm feet at night
- E. Avoid crossing the legs when sitting
- F. Use a heating blanket when cold
Correct Answer: B,C,E,G
Rationale: Clients with peripheral vascular disease should wear warm clothing, check bath water temperature, avoid crossing legs to maintain circulation, and use sunscreen to protect skin. Electric heating pads, hot water bottles, and heating blankets risk burns due to impaired sensation.
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
- A. Halloween is getting close, isn't it.'
- B. Do you have a black cat?'
- C. What's the connection between cats, hats, and time?'
- D. Time certainly does go faster these days.'
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.