Nokea
Which of the following lab values should the nurse report to the health care provider when the client has anemia?
- A. Schilling test result, elevated.
- B. Intrinsic factor, absent.
- C. Sedimentation rate, 16 mm per hour.
- D. Red blood cells (RBCs) within normal range.
Correct Answer: B
Rationale: An absent intrinsic factor is a critical finding in clients with anemia, as it indicates pernicious anemia, a condition where the body cannot absorb vitamin B12 due to a lack of intrinsic factor. This requires immediate medical attention and lifelong B12 supplementation. An elevated Schilling test is not a standard result (the test measures B12 absorption), a sedimentation rate of 16 mm/hour is normal, and normal RBCs do not explain anemia.
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Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.
The physician prescribes metoclopramide hydrochloride (Reglan) for the client with hiatal hernia. The nurse plans to instruct the client that this drug is used in hiatal hernia therapy to accomplish which of the following objectives?
- A. Increase tone of the esophageal sphincter.
- B. Neutralize gastric secretions.
- C. Ease gastric emptying.
- D. Reduce secretion of digestive juices.
Correct Answer: C
Rationale: Metoclopramide promotes gastric emptying, reducing the volume of gastric contents that can reflux in hiatal hernia.
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Excessive sweating above the injury level.
- D. Numbness in the lower extremities.
Correct Answer: C
Rationale: Excessive sweating above the injury level is a hallmark symptom of autonomic dysreflexia, a medical emergency.
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
- A. Anorexia.
- B. Tachycardia.
- C. Weight gain.
- D. Cold skin.
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.