Nokea
When a client with thrombocytopenia has a severe headache, the nurse interprets that this may indicate which of the following?
- A. Stress of the disease.
- B. Cerebral bleeding.
- C. Migraine headache.
- D. Sinus congestion.
Correct Answer: B
Rationale: Thrombocytopenia increases the risk of bleeding, and a severe headache may indicate cerebral bleeding, a life-threatening complication. The nurse should prioritize this possibility over stress, migraine, or sinus issues, which are less likely in this context.
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The nurse is developing a care plan for a client with a hearing impairment. Which of the following interventions should the nurse take? Select all that apply.
- A. Ensure that the room is well lit when communicating with the client.
- B. Use non-verbal forms of communication like gestures and sign language, if applicable.
- C. Speak loudly and shout when communicating with the client.
- D. Face the client directly when speaking.
- E. Provide written information as needed.
Correct Answer: A,B,D,E
Rationale: For hearing impairment, a well-lit room aids lip-reading, non-verbal communication and facing the client directly improve understanding, and written information supports communication. Shouting can distort speech and is not effective.
A 70-year-old female is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client's childhood health history included:
- A. Chickenpox.
- B. Poliomyelitis.
- C. Rheumatic fever.
- D. Meningitis.
Correct Answer: C
Rationale: Rheumatic fever in childhood is a common cause of mitral valve disease, leading to stenosis or regurgitation later in life.
Which of the following groups would benefit most from education regarding potential risk factors for melanoma?
- A. Adults older than age 35.
- B. Senior citizens who have been repeatedly exposed to the effects of ultraviolet A and ultraviolet B rays.
- C. Parents with children.
- D. Employees of a chemical factory.
Correct Answer: B
Rationale: Senior citizens with repeated exposure to UV rays are at the highest risk for melanoma due to cumulative skin damage. Education on risk factors like UV exposure is most beneficial for this group.
A client is to receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaparin?
- A. Increase in red blood cell production.
- B. Reduction of postoperative thrombi.
- C. Decrease in postoperative bleeding.
- D. Promotion of tissue healing.
Correct Answer: B
Rationale: Enoxaparin is an anticoagulant that prevents postoperative thrombi by inhibiting clot formation, reducing the risk of deep vein thrombosis or pulmonary embolism.
When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:
- A. 0.5 to 1 inch.
- B. 1 to 1.5 inches.
- C. 1.5 to 2 inches.
- D. 2 to 2.5 inches.
Correct Answer: C
Rationale: Depressing the sternum 1.5 to 2 inches ensures adequate compression depth for effective CPR in adults, per guidelines.