The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
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Solution
When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath.
Options A, C, and D: The client with anemia is often pale in color, has weight loss, and may be hypotensive.
An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
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Solution
The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons.
Option A: The conjunctiva can have normal deposits of fat, which give a yellowish hue.
Option B: The soles of the feet can be yellow if they are calloused.
Option D: The shins would be an area of darker pigment.
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
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Solution
The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding,
Options A, B, and C: Bleeding, splenomegaly, and blood pressure changes do not occur.
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
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Solution
Taking a trip to the museum is the only answer that does not pose a threat.
Options A, B, and C: A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided.
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
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Solution
Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client.
Options A, B, and D: Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not.
A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
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Solution
The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief.
Option A: Warm environment reduces pain and minimizes sickling, it would not be a priority.
Option B: Although hydration is important, it would not require a bolus.
Option D: Demerol is acidifying to the blood and increases sickling.
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
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Solution
Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content.
Options A, B, and D do not aid in hydration and are, therefore, incorrect.
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
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Solution
It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood.
Option A: Taking hourly blood pressures with mechanical cuff is incorrect because a mechanical cuff places too much pressure on the arm.
Option C: Position in high Fowler’s with knee gatch raised is inappropriate because it impedes circulation.
Option D: Administering Tylenol is too mild an analgesic for the client in crisis.
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
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Solution
Placing the client in semi-Fowler’s position provides the best oxygenation for this client.
Options A, B, and C: Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client.
A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
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Solution
It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation.
Options A, B, and C: Body temperature, motion, and sensation would not give information regarding peripheral circulation.