Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
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Solution
Pallor, tachycardia, and a sore tongue
Option B: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet.
Options A, C, and D: Bradycardia, reduced pulse pressure, weight gain, and double vision aren’t characteristic findings in pernicious anemia.
When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
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Solution
“Avoid sharing such articles as toothbrushes and razors.”
Option C: The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in the blood. For this reason, the client shouldn’t share personal articles that may be blood-contaminated, such as toothbrushes and razors, with other family members.
Options A, B, and D: HIV isn’t transmitted by bathing or by eating from plates, utensils, or serving dishes used by a person with AIDS.
In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:
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Solution
“I’ll need to have a C-section if I become pregnant and have a baby.”
Option D: A Cesarean section delivery isn’t necessary when the mother is HIV-positive.
Option A: The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route.
Option B: The use of birth control will prevent the conception of a child who might have HIV.
Option C: It’s true that a mother whose HIV positive can give birth to a baby who’s HIV negative.
Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
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Solution
Dyspnea, tachycardia, and pallor
Option B: Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue, listlessness, irritability, and headache.
Option A: Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome (AIDS).
Option C: Nausea, vomiting, and anorexia may be signs of hepatitis B.
Option D: Itching, rash, and jaundice may result from an allergic or hemolytic reaction.
Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer?
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Solution
Carcinoembryonic antigen level
Option D: In clients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it can’t be used as a general indicator of cancer. However, it is helpful in monitoring cancer treatment because the level usually falls to normal within 1 month if treatment is successful.
Option A: An elevated acid phosphatase level may indicate prostate cancer.
Option C: An elevated alkaline phosphatase level may reflect bone metastasis.
Option B: An elevated serum calcitonin level usually signals thyroid cancer.
On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
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Solution
Hypocalcemia
Option A: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn’t directly cause serum sodium, potassium, or magnesium abnormalities.
Option B: Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery.
Options C and D: Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.
The adrenal cortex is responsible for producing which substances?
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Solution
Glucocorticoids and androgens
Option A: The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens.
Options B and D: The medulla produces catecholamines — epinephrine and norepinephrine.
Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?
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Solution
4:00 pm
Option C: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.
A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
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Solution
glycosylated hemoglobin level.
Option D: Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day lifespan of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months.
Options A and B: Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained.
Option C: Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
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Solution
Restricting fluids
Option C: To reduce water retention in a client with the SIADH, the nurse should restrict fluids.
Options A, B, and D: Administering fluids by any route would further increase the client’s already heightened fluid load.