HPA
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? A.) Vitamin B12 injections B.) Iron supplements C.) Blood transfusions D.) Vitamin B6 supplements
A.) Vitamin B12 injections Explanation: The nurse should administer vitamin B12 injections to treat pernicious anemia when diet fails to improve the anemia due to poor absorption. Iron supplements treat iron deficiency anemia, rather than pernicious anemia. Blood transfusions do not resolve pernicious anemia. Vitamin B6 supplements are not used to treat pernicious anemia as failure to absorb vitamin B12 is the cause of the anemia.
Dietary Potassium
Low intake associated with an elevation in blood pressure and increased stroke risk High intake found to decrease blood pressure
Benazepril
an angiotensin-converting-enzyme (ACE) inhibitor that is used in the treatment of hypertension
High-Density Lipoprotein (HDL)
collect cholesterol from tissues and the vascular epithelium, decreasing the incidence of atherosclerosis, one of the contributing factors for the development of hypertension. a low level is a risk factor in the development of hypertension. The expected reference range: -Men: > 45 mg/dL - Women: >55 mg/dL
Calcium and Magnesium
2 electrolytes impacting blood pressure if dietary consumption of both is low, may result in hypertension
A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods? A.) Milk and cheese B.) Red meat and organ meat C.) Fresh fruits D.) Whole grain breads
B.) Red meat and organ meat Explanation: This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia. Dairy products are good sources of high-quality, complete protein and calcium, but not iron. Fruits are good sources of vitamins A and C, but not iron. Whole grain breads are rich in carbohydrates and dietary fiber, but not iron.
A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? A.) Liver B.) Milk C.) Beans D.) Eggs
C.) Beans Explanation: Any food that does not contain animal products does not contain cholesterol. Beans are a good source of protein for a client who follows a low-cholesterol diet. Liver and other organ meats are from animal sources and are therefore high in cholesterol content. Dairy products, including whole milk and butter, are from animal sources and therefore contain cholesterol. Egg yolks contain cholesterol. Egg whites, however, are cholesterol-free.
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching? A.) "I will sit on the side of the tub and soak my right leg two times every day." B.) "I'll keep a heating pad on the calf of my right leg when I am lying down." C.) "I'll place my leg under a heat lamp every 3 hours." D.) "I'll wrap a warm, wet towel around my right calf every 4 hours."
D.) "I'll wrap a warm, wet towel around my right calf every 4 hours." Explanation: Moist heat is more effective than dry heat in treating cellulitis. Moist heat relieves the manifestations of inflammation by increasing blood flow to the affected area. The nurse should instruct the client to elevate the right leg 8 to 15 cm (3 to 6 in) above the level of the heart and apply warm, moist heat to the site every 2 to 4 hr. Dry heat is not effective in the treatment of cellulitis. A heating pad uses dry heat, but cellulitis treatment requires a moist heat application every 2 to 4 hr. The nurse should instruct the client to elevate the calf when applying heat, rather than dangling it in water.
Medications that can cause secondary hypertension
Glucocorticoids Mineralocorticoids Sympathomimetics
A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include? A.) Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg. B.) Orthostatic hypotension increases a client's risk of a fall. C.) Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. D.) Orthostatic hypotension increases a client's risk of a pulmonary emboli.
B.) Orthostatic hypotension increases a client's risk of a fall. Explanation: Orthostatic hypotension is a decrease in blood pressure when a client changes from lying down to sitting or standing. The drop in blood pressure can cause the client to become dizzy and increases the client's risk for a fall. Orthostatic hypotension is a decrease in diastolic blood pressure of at least 10 mm Hg. Orthostatic hypotension is a decrease in systolic blood pressure of at least 20 mm Hg. A deep vein thrombosis increases a client's risk of a pulmonary emboli.
A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? A.) Sweat test B.) Haptoglobin C.) Antinuclear antibodies D.) Schilling test
D.) Schilling test Explanation: The Schilling test helps determine the cause of vitamin B12 deficiency, which leads to pernicious anemia. The sweat test helps diagnose cystic fibrosis. Haptoglobin testing helps diagnose hemolytic anemia. Antinuclear antibody testing helps diagnose a variety of autoimmune disorders, including systemic lupus erythematosus.
A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? A.) "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." B.) "Relax, you'll be asleep for most of the procedure and you won't remember a thing." C.) "I will call your doctor and tell him you still have questions about the procedure." D.) "I can understand because you must be very worried about what the biopsy will show."
A.) "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." Explanation: The client is seeking information. This open-ended therapeutic response gives the client the information that the client needs to cope, reassures the client of the nurse's presence, and encourages further communication. The client is seeking information. This nontherapeutic response devalues the client's feelings and makes two promises that the nurse cannot possibly keep. This closed-ended, nontherapeutic response puts the client's concerns on hold and focuses on an inappropriate person (the doctor). The client is seeking information that the nurse is able to give independently. While the response, "I can understand because you must be very worried about what the biopsy will show," is an example of a therapeutic response that focuses on the client's feelings, it does not reassure the client on the procedure.
A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection? A.) "You seem upset about taking your blood pressure medication." B.) "Why do you feel afraid to take your medication?" C.) "You won't get better until you take your medication?" D.) "Did your symptoms occur before or after you took the medication?"
A.) "You seem upset about taking your blood pressure medication." Explanation: "You seem upset about taking your blood pressure medication.": This statement is a reflective comment that describes the patient's feelings. A reflective comment repeats what a patient has said or describes the person's feelings. "Why do you feel afraid to take your medication?": The nursing example of therapeutic communication is of questioning and asking "why" questions, not reflection. "You won't get better until you take your medication?": The nursing example of therapeutic communication is of giving advice, not reflection. "Did your symptoms occur before or after you took the medication?": The nursing example of therapeutic communication is a closed-ended question, not reflection.
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching? A.) A slice of cheese B.) A jam sandwich C.) A cup of plain popcorn D.) A small container of applesauce
A.) A slice of cheese Explanation: The client should limit the intake of cheese due to high levels of fat and sodium. A jam sandwich is low in fat, sodium, and cholesterol; therefore, the client should include this as an acceptable snack choice. Popcorn is low in fat, sodium, and cholesterol; therefore, the client should include this as an acceptable snack choice. Applesauce is low in fat, sodium, and cholesterol; therefore, the client should include this as an acceptable snack choice.
A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis? A.) Albumin B.) Calcium C.) Sodium D.) Potassium
A.) Albumin Explanation: Albumin levels reflect the overall body protein status and is used to detect metabolic and liver dysfunction. Calcium laboratory value will not give the nurse an assessment of the adequacy of the client's protein uptake and synthesis. Serum calcium levels are used to detect neuromuscular, cardiovascular, and intestinal dysfunctions. Sodium laboratory value will not give the nurse an assessment of the adequacy of the client's protein uptake and synthesis. Serum sodium levels are used to detect cerebral, neuromuscular, gastrointestinal, and cardiovascular dysfunctions. Potassium laboratory value will not give the nurse an assessment of the adequacy of the client's protein uptake and synthesis. Serum potassium levels are used to detect musculoskeletal, respiratory, cardiovascular, and neuromuscular dysfunctions.
A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? A.) Asthma B.) Glaucoma C.) Depression D.) Migraines
A.) Asthma Explanation: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation. Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not contraindicated in a client who has glaucoma. Beta-blockers are contraindicated in clients who have AV heart block, but are not contraindicated in clients who have depression. Beta-blockers are used for prophylactic treatment of migraine headaches.
A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first? A.) Evaluate the firmness of the uterus. B.) Initiate oxygen therapy by nonrebreather mask. C.) Administer oxytocin infusion. D.) Obtain a type and crossmatch.
A.) Evaluate the firmness of the uterus. Explanation: The first action the nurse should take using the nursing process is to assess the client. A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony. The nurse should initiate oxygen therapy via a nonrebreather mask to improve oxygen delivery to the client; however, there is another action the nurse should take first. The nurse should administer oxytocin infusion to increase contractility of the uterus; however, there is another action the nurse should take first. The nurse should obtain a type and crossmatch in case the client will need to have a transfusion; however, there is another action the nurse should take first.
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A.) Fatigue B.) Hypertension C.) Bradycardia D.) Diarrhea
A.) Fatigue Explanation: The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs. Hypotension is manifestation of anemia due to blood loss following surgery. Tachycardia is manifestation of anemia due to blood loss following surgery. Constipation is a manifestation of anemia due to blood loss following surgery.
A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair." Which of the following information should the nurse clarify? A.) Location of blood pressure cuff B.) Position of the client C.) Systolic blood pressure D.) Unit of measurement
A.) Location of blood pressure cuff Explanation: The location of the blood pressure cuff requires clarification to ensure accurate documentation. The position of the client is sitting up in a chair. The systolic blood pressure is 102 mm Hg. The unit of measurement is mm Hg.
A nurse case manager for an employer-sponsored health insurance plan is implementing a program to control costs associated with hypertension. Which interventions should the nurse implement to help with cost control on a tertiary prevention level? Select all that apply. A.) Medication adherence program B.) Blood pressure screening events for all employees C.) Education about the risk factors for hypertension D.) Promoting meditation for all employees E.) Walking program for employees who have hypertension
A.) Medication adherence program E.) Walking program for employees who have hypertension Explanation: Medication adherence program is correct. Tertiary prevention aims to limit further complications for a client who has a condition. The implementation of a medication adherence program will decrease health care costs. The nurse should implement a medication adherence program to help with cost control on a tertiary prevention level. Walking program for employees who have hypertension is correct. A walking program for employees who have hypertension will assist with controlling costs on a tertiary level. Since they have the condition, walking would prevent further complications. Blood pressure screening events for all employees is incorrect. Blood pressure screening events will assist with secondary prevention level costs. This will ensure that everyone is aware about their blood pressure and identify those at risk. Education about the risk factors for hypertension is incorrect. Education about the risk factors for hypertension assists with controlling costs on a primary prevention level. The education provided will increase awareness. Promoting meditation for all employees is incorrect. Mediation assists with relaxation and blood pressure control on a primary prevention level. This is therapeutic for all.
A nurse is creating a community wellness program for a group of community members who have been identified as having an increased risk of developing hypertension. Which of the following actions should the nurse include as secondary prevention? A.) Obtain blood cholesterol levels B.) Eating a low fat diet C.) Blood pressure follow-up visits every 6 months D.) Provider prescribing antihypertensive medication
A.) Obtain blood cholesterol levels Explanation: Obtaining blood cholesterol levels would be a secondary prevention intervention aimed at screening at risk community members. Secondary prevention will focus on further illness or injury. Eating a low fat diet would be a primary prevention method to help reduce the risk of developing hypertension. Having blood pressure follow-up visits every 6 months would be a tertiary prevention intervention to assist with preventing complications that can arise from uncontrolled hypertension. Having a prescription for an antihypertensive medication would be a tertiary prevention intervention to assist with preventing complications that can arise from uncontrolled hypertension.
A nurse is teaching a class about documenting blood pressure. The nurse should include to document which of the following information? Select all that apply. A.) The site where the blood pressure was obtained. B.) Interventions implemented in response to a client's blood pressure. C.) A client's position when the blood pressure was obtained. D.) The frequency in which a blood pressure is taken. E.) A client's response to interventions implemented.
A.) The site where the blood pressure was obtained. B.) Interventions implemented in response to a client's blood pressure. C.) A client's position when the blood pressure was obtained. E.) A client's response to interventions implemented. Explanation: The site where the blood pressure was obtained is correct. The nurse should document the site where the blood pressure was taken. This information might be needed in evaluation of future blood pressure measurements. Interventions implemented in response to a client's blood pressure is correct. The nurse should document interventions implemented in response to a client's blood pressure, such as changing the client's position. A client's position when the blood pressure was obtained is correct. The nurse should document a client's position when the blood pressure was obtained. This information might be needed in evaluation of future blood pressure measurements. The frequency in which a blood pressure is taken is incorrect. The nurse does not need to document routine client care, such as frequency of vital signs. A client's response to interventions implemented is correct. The nurse should document the client's response to interventions implemented. This information might be needed in evaluation of future blood pressure measurements.
A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide? A.) Wash the affected area with soap and water before applying cream. B.) Increase intake of fluids while using this medication. C.) The medication might cause temporary blurred vision. D.) Apply the cream to large areas around the infection.
A.) Wash the affected area with soap and water before applying cream. Explanation: The client should wash the affected area with soap and water and dry it thoroughly before applying the cream. The client should increase fluid intake while taking the IV or IM form of gentamicin, not the topical cream. The ophthalmic form of gentamicin can cause temporary blurring of vision, not the topical cream. The client should only apply the cream to the affected skin area.
A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? A.) "I flavor my meat with lemon juice." B.) "I eat two eggs for breakfast each morning." C.) "I cook my food with canola oil." D.) "I take an omega-3 supplement daily."
B.) "I eat two eggs for breakfast each morning." Explanation: Clients should limit egg yolks to two to three per week. Lemon juice is a good alternative to high-fat sauces. Canola and olive oil are monounsaturated fats and lower LDL cholesterol and raise HDL cholesterol. Including omega supplements in the diet can help lower cholesterol levels.
A nurse is assessing for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? A.) Apical pulse rate is different than the radial pulse rate B.) Decrease in systolic pressure by more than 10 mm Hg during inspiration C.) Increase in heart rate by 20% when moving from sitting to standing D.) Drop in systolic BP by 20 mm Hg when changing positions
B.) Decrease in systolic pressure by more than 10 mm Hg during inspiration Explanation: The nurse should expect a client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or cardiac tamponade. The nurse should collect more data if the client's apical pulse rate is different than the radial pulse rate, also known as a pulse deficit. The nurse should check for orthostatic hypotension when the client's pulse rate increases by 20% when moves from sitting to standing. The nurse should check for orthostatic hypotension when the client's systolic BP drops by 20 mm Hg when changing position.
A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories? A.) Within the expected reference range B.) Elevated C.) Stage 1 hypertension D.) Stage 2 hypertension
B.) Elevated Explanation: A blood pressure of 124/79 mm Hg places this client in the elevated, or prehypertension, category. An elevated blood pressure, or prehypertension, is indicated by a systolic pressure between 120 and 129 mm Hg and a diastolic pressure of less than 80 mm Hg. The expected reference range for blood pressure is a systolic pressure less than 120 mm Hg and a diastolic pressure less than 80 mm Hg. Stage 1 hypertension presents with a systolic pressure between 130 and 139 mm Hg and a diastolic pressure between 80 and 89 mm Hg. Stage 2 hypertension presents with a systolic pressure of equal to or greater than 140 mm Hg and a diastolic pressure of equal to or greater than 90 mm Hg.
A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? A.) Elevate the client's feet. B.) Increase the client's IV fluid rate. C.) Initiate a dopamine IV infusion for the client. D.) Administer a unit of packed RBCs.
B.) Increase the client's IV fluid rate. Explanation: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to increase the client's IV fluid rate. Providing fluid to the client will restore circulating volume and increase blood pressure. The nurse should elevate the client's feet to increase perfusion to the brain during the hypotensive episode, but this action is not the priority. The nurse might need to initiate a dopamine IV infusion to treat the client's hypotension, but this action is not the priority. D.) Administer a unit of packed RBCs.
A nurse is planning care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take? A.) Encourage the client to use guided imagery to relax. B.) Increase the client's fluid intake. C.) Instruct the client to perform the Valsalva maneuver. D.) Elevate the head of the client's bed.
B.) Increase the client's fluid intake. Explanation: The nurse should increase the client's fluid intake to increase circulatory blood volume and blood pressure. The nurse should instruct a client who has tachycardia and hypertension to use guided imagery to relax. The nurse might instruct a client who has tachycardia to perform the Valsalva maneuver to decrease the heart rate. The nurse should lower the client's head of bed to promote venous return.
A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide? A.) Take the medication on an empty stomach to decrease gastrointestinal irritation. B.) Take the medication with orange juice to enhance absorption. C.) Take the medication with milk. D.) Rinse the mouth before taking the iron.
B.) Take the medication with orange juice to enhance absorption. Explanation: Taking iron on an empty stomach may increase gastrointestinal side effects. Ascorbic acid (vitamin C), found in orange juice, will enhance the absorption of iron and increase its bioavailability. This will also help to decrease the gastrointestinal side effects of iron. Iron should not be taken with milk or antacids, because it decreases the absorption. The client should rinse the mouth after taking the ferrous sulfate liquid to prevent the medication from staining the teeth.
A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? A.) The client will list foods that are high in calcium, which should be avoided. B.) The client will walk for 30 min 5 days a week. C.) The client will increase calorie intake by 200 cal per day. D.) The client will replace cigarettes with smokeless tobacco products.
B.) The client will walk for 30 min 5 days a week. Explanation: CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week. Female clients are at increased risk for osteoporosis; therefore, the nurse should instruct the client to increase intake of calcium and vitamin D. The client's BMI indicates the client is overweight; therefore, the nurse should counsel the client on weight reduction strategies. Smokeless tobacco delivers a higher concentration of nicotine and places the client at risk for cancer. The nurse should discuss nicotine replacement and acupuncture as measures to stop smoking tobacco products.
A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching? A.) "Monitor your child's temperature daily." B.) "Restrict outdoor play activity to 1 hour per day." C.) "Offer fluids to your child multiple times every day." D.) "Apply cold compresses when your child expresses pain."
C.) "Offer fluids to your child multiple times every day." Explanation: Preventing dehydration is an important step in preventing a sickle cell crisis. The nurse should provide the parents with a specific fluid goal for the child to reach each day. The parents need to check the child's temperature only when they suspect fever, and when they do, they should report it to the provider immediately. Fever is a manifestation of acute chest syndrome, a complication of sickle cell anemia. The nurse should instruct the parent to restrict the child from playing contact sports. Heat applications can be soothing but cold compresses should be avoided because they cause vasoconstriction.
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make? A.) "Taking the medication between meals will help you avoid becoming constipated." B.) "Taking the medication with food increases the risk of esophagitis." C.) "Taking the medication between meals will help you absorb the medication more efficiently." D.) "The medication can cause nausea if taken with food."
C.) "Taking the medication between meals will help you absorb the medication more efficiently." Explanation: Ferrous sulfate provides the iron needed by the body to produce red blood cells. Taking iron supplements between meals helps to increase the bioavailability of the iron. Taking the medication with food can reduce the GI symptoms associated with it. However, taking the medication between meals maximizes absorption. Reclining immediately after taking ferrous sulfate may lead to esophageal corrosion. Clients should remain upright for 15-30 min following administering. Taking ferrous sulfate with food can reduce the GI symptoms associated with it. However, taking the medication between meals maximizes absorption.
A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include? A.) "Allow your skin to air dry after bathing." B.) "Rub your skin firmly when cleaning." C.) "Use a moisturizer on your skin after cleaning." D.) "Wash your skin daily with hot water."
C.) "Use a moisturizer on your skin after cleaning." Explanation: The client should gently dry their skin with a towel after bathing. Allowing skin to air dry might result in the client having areas on the body that remain moist leading to maceration and impaired skin integrity, which place the client at an increased risk for infection. The client should avoid rubbing the skin firmly as this might cause skin abrasions, which can place the client at an increased risk for infection. The client should use gentle moisturizers on the skin to promote hydration and protect the skin from injury that might lead to an infection. The client should use warm water to wash the skin. Using hot water causes the skin to become dry. Dry skin is more susceptible to damage and injury than moisturized skin and places the client at an increased risk for infection.
A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take? A.) Leave the client 5 min after beginning the transfusion. B.) Infuse the transfusion at a rate of 200 mL/hr. C.) Check the client's vital signs every hour during the transfusion. D.) Flush the blood tubing with dextrose 5% in water.
C.) Check the client's vital signs every hour during the transfusion. Explanation: The nurse should remain with the client for 15 to 30 min after the start of the transfusion to monitor for a reaction, which usually occurs during the first 50 mL of the transfusion. The transfusion should infuse in 2 to 4 hr to prevent fluid overload. The nurse should check the client's vital signs every 15 min at the start of the transfusion, then every 1 hr to monitor for a transfusion reaction. The nurse should flush the blood tubing with 0.9% sodium chloride to prevent hemolysis of the blood.
A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia? A.) Dietary iron restrictions B.) Intestinal malabsorption syndrome C.) Chronic blood loss D.) Intestinal parasites
C.) Chronic Blood Loss Explanation: Dietary approaches to ulcerative colitis do not restrict iron; in fact, they often include supplemental iron in an attempt to prevent anemia. Ulcerative colitis is an inflammatory bowel disease affecting primarily the sigmoid colon and rectum, although the entire colon may be affected. A malabsorption syndrome is more likely to be caused by a condition affecting the small intestine. A client with long-standing ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that occurs over time, although the colitis may result in erosion of the intestine and hemorrhage. These clients often report bloody stools and are therefore at increased risk for developing anemia. Intestinal parasites are not a manifestation of ulcerative colitis. This inflammatory bowel disease can cause dehydration, fever, weight loss and anorexia.
A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? A.) Enforce strict bedrest for 3 days. B.) Apply fresh ice packs every 4 hr. C.) Elevate the affected leg on two pillows. D.) Apply antibiotic ointment to the wound with dressing changes.
C.) Elevate the affected leg on two pillows. Explanation: Cellulitis is an acute inflammation of the deep connective tissue of the skin, caused by infection, The edema of the inflammatory response puts the client at risk for skin breakdown. Elevation of the affected area and frequent repositioning reduces dependent edema and assists in the healing process. Strict bedrest can lead to many complications of immobility and should not be imposed on the client. Applying ice every 4 hours is not appropriate. The application of cold decreases circulation (causing vasoconstriction) and is often used to reduce swelling but the edema of cellulitis is a result of infection and will diminish as the infection resolves. A client with cellulitis has an infection that has spread beyond the wound and into the surrounding tissues. This client requires a systemic antibiotic; topical antibiotics will be ineffective.
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia? A.) Folic acid deficiency anemia B.) Pernicious anemia C.) Iron-deficiency anemia D.) Sickle cell anemia
C.) Iron-deficiency anemia Explanation: Iron-deficiency anemia results from poor gastrointestinal absorption of iron, a diet that is deficient in iron, or blood loss. The nurse should expect a client who has iron-deficiency anemia to have weakness, pallor, fatigue, reduced tolerance for activity, and cheilosis (ulcerations of the corners of the mouth). The nurse should expect a client who has folic acid deficiency to have pallor and jaundice; a smooth, beefy-red tongue (glossitis); fatigue; and weight loss. This type of anemia is caused by nutritional deficiencies, malabsorption syndromes (Crohn's disease), and medications (e.g., anticonvulsants, oral contraceptives). A client who has pernicious anemia is unable to absorb vitamin B12 due to a lack of intrinsic factors in the stomach. The nurse should expect this client to have pallor and jaundice; a smooth, beefy-red tongue (glossitis); fatigue; weight loss; and paresthesias to the hands and feet. Sickle cell anemia is an autosomal recessive disorder in which the RBCs develop a sickle shape following conditions in which decreased oxygen is available. These sickled cells then clump together and become fragile, causing tissue ischemia leading to eventual organ damage. Manifestations of sickle cel anemia include pain, pallor, cyanosis, dyspnea, fatigue, and weakness.
A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan? A.) Discourage a high level of fluid intake. B.) Apply cold compresses to painful, swollen joints. C.) Observe for indications of hypokalemia. D.) Administer meperidine every 4 hr for pain.
C.) Observe for indications of hypokalemia. Explanation: The nurse should observe the child for indications of hypokalemia. Diuresis can result in electrolyte loss, leading to hypokalemia. The nurse should encourage a high level of fluid intake. The nurse should apply heat to painful areas. Cold therapy promotes vasoconstriction and sickling. Meperidine is not recommended for children who have sickle cell anemia because of the increased risk for seizure activity.
A nurse is teaching a client who has hypertension and a new prescription for a low sodium diet. Which of the following teaching methods uses the cognitive domain of learning? Select all that apply. A.) Ask the client how they are feeling about starting a low sodium diet. B.) Encourage the client to share their thoughts in a support group. C.) Observe the client choose low sodium foods. D.) Review strategies to reduce sodium intake. E.) Discuss the physiology of hypertension with the client.
C.) Observe the client choose low sodium foods. D.) Review strategies to reduce sodium intake. E.) Discuss the physiology of hypertension with the client. Explanation: Ask the client how they are feeling about starting a low sodium diet is incorrect. Asking the client how they are feeling about the low sodium diet involves exploring the client's emotions and is associated with the affective domain of learning. Encourage the client to share their thoughts in a support group is incorrect. Encouraging the client to share their thoughts in a support group involves exploring the client's emotions and feelings and is associated with the affective domain of learning. Observe the client choose low sodium foods is correct. Observing the client choose low sodium foods utilizes the application, understanding, and thinking processes associated with the cognitive domain of learning. Review strategies to reduce sodium intake is correct. Reviewing strategies to reduce sodium intake with the client utilizes the understanding and thinking processes associated with the cognitive domain of learning. Discuss the physiology of hypertension with the client is correct. Discussing the physiology of hypertension with the client utilizes understanding and thinking processes associated with the cognitive domain of learning.
A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? A.) High-density lipoprotein (HDL) level of 70 mg/dL B.) A diet high in potassium C.) Obstructive sleep apnea (OSA) D.) Taking benazepril
C.) Obstructive sleep apnea (OSA) Explanation: The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal. HDL is an important factor in the role of cardiovascular health and the development of hypertension. HDLs collect cholesterol from tissues and the vascular epithelium, decreasing the incidence of atherosclerosis, one of the contributing factors for the development of hypertension. The nurse should identify a low HDL level as a risk factor in the development of hypertension. However an HDL level of 70 mg/dL places the client at a low risk for the development of hypertension and heart disease. The expected reference range for HDL is >45 mg/dL in men and >55 mg/dL in women. The nurse should include diet as a factor in the development or prevention of hypertension. Low dietary potassium intake has been associated with an elevation in blood pressure and an increased risk of stroke, while a diet high in potassium has been found to decrease blood pressure. Other electrolytes impacting blood pressure include calcium and magnesium, both of which can result in hypertension if dietary consumption is low. The nurse should include medications that can cause secondary hypertension such as glucocorticoids, mineralocorticoids, and sympathomimetics. Benazepril is an angiotensin-converting-enzyme (ACE) inhibitor that is used in the treatment of hypertension.
A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is effective? A.) The client reports dizziness. B.) The client reports nausea. C.) The client's systolic blood pressure decreases from 110 mm Hg to 105 mm Hg. D.) The client's heart increases from 100/min to 108/min.
C.) The client's systolic blood pressure decreases from 110 mm Hg to 105 mm Hg. Explanation: Orthostatic hypotension is a decrease in systolic blood pressure of at least 20 mm Hg or a decrease on diastolic blood pressure of at least 10 mm Hg. Therefore, the intervention was effective. Dizziness is a manifestation of postural hypotension and places the client at risk for a fall. Nausea is a manifestation of postural hypotension. Tachycardia is a manifestation of postural hypotension.
A nurse is reviewing laboratory values for a client. Which of the following findings indicates the presence of an infection? A.) Creatine kinase 75 units/L B.) Platelet count 200,000/mm3 C.) WBC count 22,000/mm3 D.) Hgb 15 g/dL
C.) WBC count 22,000/mm3 Explanation: The client's WBC count is greater than the expected reference range of 5,000 to 10,000/mm3. An elevated WBC count is a manifestation of an infection. The client's creatine kinase is within the expected reference range. Creatinine kinase is a marker that increases with injury to cardiac muscle, skeletal muscle, and neurologic disease. It does not indicate inflammation. The client's platelet count is within the expected reference range. A decrease in platelet count can result in impaired clotting and an increase in platelet count can indicate a malignant disorder. The client's Hgb is within the expected reference range. A decrease in Hgb is a manifestation of anemia and an increase in Hgb is a manifestation of dehydration.
A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching? A.) Aplastic anemia is associated with a decreased intake of iron. B.) Aplastic anemia results in an increased rate of RBC destruction. C.) Aplastic anemia results in an inability to absorb vitamin B12. D.) Aplastic anemia results from decreased bone marrow production of RBCs.
D.) Aplastic anemia results from decreased bone marrow production of RBCs. Explanation: Aplastic anemia is a hypoproliferative anemia resulting from decreased production of RBC within the bone marrow. An inadequate intake of iron can result in iron deficiency anemia rather than aplastic anemia. Autoimmune hemolytic anemia, rather than aplastic anemia, is associated with an increased rate of RBC destruction. Pernicious anemia is seen in clients who lack the intrinsic factor responsible for vitamin B12 absorption.
A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first? A.) Determine the client's blood pressure 1 min after each position change. B.) Assist the client into a standing position. C.) Place the client in a sitting position D.) Check the blood pressure with the client in a supine position.
D.) Check the blood pressure with the client in a supine position. Explanation: According to evidence-based practice the first action the nurse should take when measuring a client for orthostatic hypotension, is to check the blood pressure with the client in a supine position. The supine position provides a baseline reading for the nurse to compare the client's blood pressure. A decrease of at least 20 mm Hg in the systolic pressure with a position change indicates orthostatic hypotension. The nurse should determine the client's blood pressure 1 min after each position change when measuring for orthostatic hypotension; however, evidence-based practice indicates that the nurse should take a different action first. The nurse should assist the client into a standing position when measuring for orthostatic hypotension; however, evidence-based practice indicates that the nurse should take a different action first. The nurse should assist the client into a sitting position when measuring for orthostatic hypotension; however, evidence-based practice indicates that the nurse should take a different action first.
A nurse is caring for a client who has sickle cell disease. Nurses' Notes 0800: Client reports fatigue, muscle weakness, joint pain, and dyspnea. Sclerae is jaundiced. 2.5 cm (1 in) by 2.5 cm (1 in) open ulcer noted on inner left ankle. Vital Signs 0800: Temperature 37.5° C (99.5° F) Blood pressure 122/68 mm Hg Heart rate 95/min Respiratory rate 28/min Oxygen saturation 95% on room air 1000: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 112/min Respiratory rate 26/min, labored Oxygen saturation 90% on room air Diagnostic Results 1000: Hct 26% (37% to 47%) Hgb 8 g/dL (12 to 16 g/dL) For each client finding, click to specify if the finding is consistent with sickle cell disease, iron deficiency anemia, or leukemia. Each finding may support more than 1 disease process. -Respiratory status -Joint pain -Heart rate at 1000 -Jaundice -Ankle ulcer
Respiratory Status: -Sickle Cell Disease -Iron Deficiency Anemia -Leukemia Respiratory status is consistent with sickle cell disease, iron deficiency anemia, and leukemia. In sickle cell disease, iron deficiency anemia, and leukemia, dyspnea occurs to compensate for decreased hematocrit and hemoglobin. Joint Pain: -Sickle Cell Disease -Leukemia Joint pain is consistent with sickle cell disease and leukemia. In sickle cell disease and leukemia, impaired function of the bone marrow can result in joint pain and swelling. Heart rate at 1000: -Sickle Cell Disease -Iron Deficiency Anemia -Leukemia Heart rate at 1000 (112 bpm) is consistent with sickle cell disease, iron deficiency anemia, and leukemia. In sickle cell disease, iron deficiency anemia, and leukemia, heart rate increases to increase perfusion to the tissues and to compensate for a decreased hematocrit and hemoglobin. Jaundice: -Sickle Cell Disease Jaundice is consistent with sickle cell disease. In sickle cell disease, jaundice can occur due to destruction of red blood cells and the release of bilirubin. Ankle Ulcer: -Sickle Cell Disease Ankle ulcer is consistent with sickle cell disease. In sickle cell disease, decreased perfusion can result in ulcers of the lower extremities.
