Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
A. Loss of hearing
Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting
Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.
C. Paresthesia
Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
D. Changes in vision
While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.
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Full Explanation
C. Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
A. Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.
D. While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.
Similar Questions
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
A. Emesis of 250 mL
Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. Increased respiratory rate to 26/min
While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
C. Decreased anxiety
Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
D. Decreased urinary output
Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.
Full Explanation
C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.
A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's?
A. A history of herpes zoster
While herpes zoster (shingles) is a viral infection caused by the varicella-zoster virus, it is not directly associated with triggering Raynaud's attacks.
B. Taking amlodipine for hypertension
Amlodipine is a calcium channel blocker medication commonly used to treat hypertension.
C. Using a nicotine transdermal patch
Nicotine is a vasoconstrictor, meaning it causes narrowing of blood vessels. Therefore, using a nicotine transdermal patch can exacerbate Raynaud's attacks by promoting vasoconstriction and reducing blood flow to the extremities.
D. Eating a strict vegetarian diet
While diet can potentially influence overall health and vascular function, there is no direct evidence to suggest that a strict vegetarian diet would trigger exacerbations of Raynaud's disease.
Full Explanation
C. Nicotine is a vasoconstrictor, meaning it causes narrowing of blood vessels. Therefore, using a nicotine transdermal patch can exacerbate Raynaud's attacks by promoting vasoconstriction and reducing blood flow to the extremities.
A. While herpes zoster (shingles) is a viral infection caused by the varicella-zoster virus, it is not directly associated with triggering Raynaud's attacks.
B. Amlodipine is a calcium channel blocker medication commonly used to treat hypertension.
D. While diet can potentially influence overall health and vascular function, there is no direct evidence to suggest that a strict vegetarian diet would trigger exacerbations of Raynaud's disease.
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
A. Increase the room temperature.
Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. Cleanse the client's wounds.
While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Administer analgesic medication.
Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention
D. Start an IV with a large-bore needle.
Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
Full Explanation
D. Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
A. Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention