Nokea
Which of the following assessment findings should alert the nurse that the elderly client should be evaluated for pernicious anemia?
- A. Clubbing of the nails
- B. Bloody stools
- C. Beefy-red tongue
- D. Enlarged lymph nodes
Correct Answer: C
Rationale: A beefy-red tongue is a classic symptom of pernicious anemia due to vitamin B12 deficiency.
You may also like to solve these questions
The nurse writes a client problem of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Pace activities according to tolerance.
- B. Provide supplements high in iron and vitamins.
- C. Administer packed red blood cells.
- D. Monitor vital signs every four (4) hours.
Correct Answer: A
Rationale: Pacing activities (A) conserves energy in anemia-related activity intolerance. Supplements (B) and transfusions (C) are medical, and vitals (D) are routine, not primary.
The client diagnosed with anemia is admitted to the emergency department with dyspnea, cool pale skin, and diaphoresis. Which assessment data warrant immediate intervention?
- A. The vital signs are T 98.6°F, P 116, R 28, and BP 88/62.
- B. The client is allergic to multiple antibiotic medications.
- C. The client has a history of receiving chemotherapy.
- D. ABGs are pH 7.35, Pco2 44, Hco3 22, Pao2 92.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (A) indicate severe anemia with hypoxia, requiring immediate action. Allergies (B), chemo history (C), and normal ABGs (D) are secondary.
When reviewing the morning serum laboratory results of the client with multiple myeloma, the nurse sees that the total calcium level is 13.2 mEq/L. Which interventions, if prescribed by the HCP, should the nurse plan to implement?
- A. Encourage fluid intake.
- B. Maintain strict bedrest.
- C. Administer furosemide IV.
- D. Give allopurinol by mouth.
- E. Offer foods high in calcium.
Correct Answer: C
Rationale: A, C: A. Adequate hydration dilutes calcium and prevents precipitates from causing renal tubular obstruction. B. The client with multiple myeloma is encouraged to ambulate because weight-bearing activities can help the bone resorb some calcium as well as prevent thrombosis that can accompany immobility. C. Furosemide (Lasix) given IV can promote the excretion of calcium when hypercalcemia exists due to multiple myeloma. D. Allopurinol (Zyloprim) may be administered to reduce the hyperuricemia that can accompany multiple myeloma, not the hypercalcemia. E. The serum calcium level is elevated (normal is 9–10.5 mg/dL). Foods high in calcium would not be offered. However, limiting the intake of foods high in calcium will not make any difference to the elevated calcium level that is caused by cancer.
The 33-year-old client diagnosed with Stage IV Hodgkin’s lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client?
- A. Instruct the client to continue scheduled screenings for cancer.
- B. Discuss the need for follow-up appointments every five (5) years.
- C. Teach the client that the cancer risk is the same as for the general population.
- D. Have the client talk with the family about funeral arrangements.
Correct Answer: A
Rationale: Post-remission Hodgkin’s requires ongoing cancer screenings (A) due to recurrence/second cancer risk. Follow-ups are more frequent than 5 years (B), risk remains elevated (C), and funeral plans (D) are premature.
A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present?
- A. Numerous bruises on the child's body
- B. Ruddy complexion
- C. Diarrhea and vomiting
- D. Chest pain
Correct Answer: A
Rationale: Numerous bruises are common in leukemia due to decreased platelets from bone marrow failure.