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With which term will the nurse document the finding after noting multiple 1-mm red macules when assessing the skin of a patient with leukemia and thrombocytopenia?
- A. Purpura.
- B. Bruising.
- C. Petechiae.
- D. Ecchymosis.
Correct Answer: C
Rationale: Petechiae are small, red or purple 1-mm macules due to minor bleeding from broken capillaries, common in thrombocytopenia.
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A patient's blood pressure (BP) reading is 142/91 mm Hg. How would the nurse classify the BP?
- A. Normal.
- B. Prehypertension.
- C. Hypertension, stage 1.
- D. Hypertension, stage 2.
Correct Answer: C
Rationale: A BP of 142/91 mm Hg is classified as stage 1 hypertension, with systolic 140-159 mm Hg or diastolic 90-99 mm Hg.
The nurse notes that a patient has a smooth and shiny tongue surface. The nurse would attribute these findings to which condition?
- A. The patient has neutropenia.
- B. The patient has polycythemia.
- C. The patient has pernicious anemia.
- D. The patient has elevated estrogen levels.
Correct Answer: C
Rationale: Pernicious anemia causes glossitis, leading to a smooth and shiny tongue surface due to vitamin B12 deficiency.
After noting that a patient with leukemia has thrombocytopenia, which action will the nurse plan to take?
- A. Palpate lymph nodes for swelling.
- B. Check temperature for elevation.
- C. Inspect skin for bruising or petechiae.
- D. Examine oral mucosa for ulceration.
Correct Answer: C
Rationale: Inspecting the skin for bruising or petechiae is specific to thrombocytopenia, as petechiae are small, red or purple dots that appear on the skin when platelet count is low, indicating a bleeding tendency.
A patient who smokes reports chest pain while at rest. Which condition would the nurse suspect the patient is experiencing?
- A. Silent ischemia.
- B. Angina decubitus.
- C. Prinzmetal angina.
- D. Chronic stable angina.
Correct Answer: C
Rationale: Prinzmetal angina, also known as variant angina, typically occurs at rest due to coronary artery spasms, which aligns with the patient's symptoms of chest pain at rest.
Which finding would the nurse expect to see in a patient with a hemoglobin level of 8 g/dL? Select all that apply.
- A. Palpitations.
- B. Conjunctival pallor.
- C. Sternal tenderness.
- D. Heart rate of 104 beats/min.
Correct Answer: B,D
Rationale: Conjunctival pallor and tachycardia (heart rate of 104 beats/min) are common in anemia, reflecting reduced hemoglobin and compensatory mechanisms.