Question 5081)
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
Answer: C
Explanation: Early in the course of pernicious anemia, the tongue becomes beefy red and painful. Later, the tongue atrophies and becomes smooth. Nail clubbing is associated with respiratory and cardiac disorders. Numbness and tingling of the hands and feet are more common with pernicious anemia. Mild diarrhea is associated with pernicious anemia, whereas bloody stools usually are not. Colorectal bleeding is likely to lead to iron deficiency anemia. Enlarged lymph nodes are associated with leukemia, not anemia.
Question 5082)
An elderly client who is being treated for pernicious anemia needs to be monitored periodically for which of the following conditions?
A. Lactose intolerance
B. Stomach cancer
C. Dementia
D. Hearing loss
Answer: B
Explanation: The incidence of stomach cancer is increased in clients with deficiency of gastric acid. Intrinsic factor is in gastric acid. Treatment of pernicious anemia corrects the deficiency of vitamin B12 but does not alter the gastric acid production, so the client remains at risk for stomach cancer. Both lactose intolerance and hearing loss occur more commonly with aging, as does pernicious anemia. The presence of pernicious anemia does not alter the risk for either lactose intolerance or hearing loss, however. Dementia does occur in the late stages of untreated pernicious anemia, but for a client who is receiving treatment, there is no increased risk of dementia.
Question 5083)
Which of the following would be the best lunch for a client with folic acid deficiency anemia?
A. Bologna sandwich and vegetable soup
B. Grilled cheese sandwich and tomato soup
C. Coleslaw and cream of mushroom soup
D. Spinach salad and bean soup
Answer: D
Explanation: Leafy green vegetables and dried beans are good sources of folic acid. Nuts and citrus fruits are other good sources. The other options do not contain foods high in folic acid.
Question 5084)
The nurse administers iron using the Z track technique. What is the primary reason for administering iron via Z track?
A. To prevent adverse reactions
B. To prevent staining of the skin
C. To improve the absorption rate
D. To increase the speed of onset of action
Answer: B
Explanation: Iron is black and stains the skin. The Z track method of pulling the skin to one side before injecting the medications prevents staining of the skin. It also reduces pain from the medication. It does not prevent adverse reactions, improve the absorption rate, or increase the speed of onset of action
Question 5085)
The nurse is caring for a client who is thought to have pernicious anemia. What signs and symptoms would the nurse expect in this person?
A. Easy bruising
B. Beefy-red tongue
C. Fine red rash on the extremities
D. Pruritus
Answer: B
Explanation: A beefy-red tongue is characteristic of pernicious anemia. Easy bruising would be seen in a clotting disorder such as hemophilia, in leukemia, or in bone marrow depression. Pruritus is characteristic of Hodgkin’s disease. Pernicious anemia does not present a fine, red rash on the extremities.
Question 5086)
A 1-year-old is admitted to the hospital with sickle cell anemia in crisis. Upon admission, which therapy will assume priority?
A. Fluid administration
B. Exchange transfusion
C. Anticoagulant
D. IM administration of iron and folic acid
Answer: A
Explanation: Dehydration causes sickling. Sickling causes clumping and pain. The first priority of care upon admission should be the administration of fluids. Exchange transfusion, if done, is not the first priority. Anticoagulants are not the first priority. Iron and folic acid may be given but are not the first priority. They will not help stop the sickling. Folic acid and iron are necessary to make red blood cells.
Question 5087)
A toddler is diagnosed with sickle cell anemia. Her mother is four months pregnant with her second child. The mother asks if there is any chance the new baby will have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. What is the best response for the nurse to make?
A. “No. Sickle cell anemia is not inherited.”
B. “Yes. The new baby will also have sickle cell anemia.”
C. “There is a 25% chance that each child you have will have the disease.”
D. “Because neither of you has the disease, another child will not have it. You should ask your physician.”
Answer: C
Explanation: Sickle cell anemia is a recessive gene that is transmitted, giving a 25% chance that each child will have the disease. To have a child with the disease, both parents must be carriers for the disease even though neither one has the disease.
Question 5088)
The child with haemophilia is admitted to the hospital with a swollen knee joint. He is complaining of severe pain. What is the priority of nursing care for this child upon admission?
A. Maintain joint function
B. Use a bed cradle
C. Administer aspirin as needed for pain
D. Encourage fluids
Answer: B
Explanation: Hemarthrosis (bleeding into a joint) is very painful. A bed cradle will keep the bed covers off of his sore joint. Moving a bleeding joint will increase bleeding and should not be done. Aspirin is an anticoagulant and contraindicated for a hemophiliac. Fluid administration is not the priority nursing action.
Question 5089)
The nurse is caring for a child who has hemophilia. He is admitted with a bleeding episode. Which of the following should the nurse expect will be given to stop the bleeding?
A. Heparin
B. Cryoprecipitate
C. Packed cells
D. Whole blood
Answer: B
Explanation: Cryoprecipitate is frozen clotting factor and replaces the factors that the child is missing. Heparin is an anticoagulant and contraindicated for this child. Packed cells might be given after a severe hemorrhage but do not contain any clotting factors.Whole blood does not contains clotting factors.
Question 5090)
A 19-year-old college student reports to the health service with a sore throat, malaise, and fever of four days in duration. Examination shows cervical lymphadenopathy and splenomegaly. Temperature is 103°F. Blood is positive for heterophil antibody agglutination test. Which condition does the nurse expect this student to have?
A. Streptococcal sore throat
B. Infectious mononucleosis
C. Rubella
D. Influenza
Answer: B
Explanation: The findings are characteristic of infectious mononucleosis. The heterophil antibody agglutination test is diagnostic for mononucleosis. A throat culture would identify a streptococcal sore throat. Rubella (German measles) typically has a rash. The fever and sore throat are not typical of rubella. Influenza might have similar symptoms but would not have a positive heterophil agglutination test.
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