Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has sickle cell anemia. Which of the following findings is the priority for the nurse to report?
A. Slurred speech
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
B. Yellowed sclera
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
C. Ulcers on the ankles
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
D. Swelling in the joints
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.
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Full Explanation
Choice A rationale:
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
Choice B rationale:
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
Choice C rationale:
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
Choice D rationale:
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.
Similar Questions
A nurse is reviewing the laboratory report of an 8-year-old child who has nephrotic syndrome. Which of the following laboratory results should the nurse report to the provider?
A. Sodium 140 mEq/L
The sodium level of 140 mEq/L is within the normal range for children, which is 135 to 145 mEq/L. Sodium levels may be low in nephrotic syndrome due to fluid retention and dilutional hyponatremia, but this is not the case for this child.
B. Platelet count 350,000/mm3
The platelet count of 350,000/mm3 is within the normal range for children, which is 150,000 to 450,000/mm3. Platelet levels may be elevated in nephrotic syndrome due to increased production by the bone marrow in response to inflammation and infection, but this is not the case for this child.
C. Protein 2 g/dL
The nurse should report the protein level of 2 g/dL to the provider, as this is abnormally low and indicates severe proteinuria. Proteinuria is a hallmark of nephrotic syndrome, as the glomeruli become damaged and allow protein to leak into the urine. Normal protein levels for children are 6 to 8 g/dL. Low protein levels can lead to edema, hypoalbuminemia, and hyperlipidemia.
D. Cholesterol 170 mg/dL
The cholesterol level of 170 mg/dL is within the normal range for children, which is less than 200 mg/dL. Cholesterol levels may be high in nephrotic syndrome due to increased synthesis by the liver as a compensatory mechanism for low protein levels, but this is not the case for this child.
Full Explanation
Choice A rationale:
The sodium level of 140 mEq/L is within the normal range for children, which is 135 to 145 mEq/L. Sodium levels may be low in nephrotic syndrome due to fluid retention and dilutional hyponatremia, but this is not the case for this child.
Choice B rationale:
The platelet count of 350,000/mm3 is within the normal range for children, which is 150,000 to 450,000/mm3. Platelet levels may be elevated in nephrotic syndrome due to increased production by the bone marrow in response to inflammation and infection, but this is not the case for this child.
Choice C rationale:
The nurse should report the protein level of 2 g/dL to the provider, as this is abnormally low and indicates severe proteinuria. Proteinuria is a hallmark of nephrotic syndrome, as the glomeruli become damaged and allow protein to leak into the urine. Normal protein levels for children are 6 to 8 g/dL. Low protein levels can lead to edema, hypoalbuminemia, and hyperlipidemia.
Choice D rationale:
The cholesterol level of 170 mg/dL is within the normal range for children, which is less than 200 mg/dL. Cholesterol levels may be high in nephrotic syndrome due to increased synthesis by the liver as a compensatory mechanism for low protein levels, but this is not the case for this child.
A nurse is teaching a client who is at 30 weeks of gestation and has coarctation of the aorta. Which of the following statements should the nurse include regarding this congenital heart defect?
A. "You will receive terbutaline if you experience preterm labor."
Terbutaline is a medication used to inhibit uterine contractions and is not directly related to managing coarctation of the aorta.
B. "You will be encouraged to receive epidural anesthesia during labor."
Coarctation of the aorta is a congenital heart defect characterized by narrowing of the aorta, which can lead to increased pressure and decreased blood flow to the lower part of the body. During labor, epidural anesthesia is often recommended for clients with coarctation of the aorta to reduce stress and pain, as well as to maintain stable blood pressure.
C. "You will be placed in a supine position during labor."
Placing a client with coarctation of the aorta in a supine position during labor can worsen the obstruction of blood flow and is contraindicated. Left lateral positioning or other positions that enhance venous return are preferred.
D. "You have an increased risk of developing preeclampsia."
There is no established increased risk of preeclampsia in clients with coarctation of the aorta.
Full Explanation
Choice A rationale:
Terbutaline is a medication used to inhibit uterine contractions and is not directly related to managing coarctation of the aorta.
Choice B rationale:
Coarctation of the aorta is a congenital heart defect characterized by narrowing of the aorta, which can lead to increased pressure and decreased blood flow to the lower part of the body. During labor, epidural anesthesia is often recommended for clients with coarctation of the aorta to reduce stress and pain, as well as to maintain stable blood pressure.
Choice C rationale:
Placing a client with coarctation of the aorta in a supine position during labor can worsen the obstruction of blood flow and is contraindicated. Left lateral positioning or other positions that enhance venous return are preferred.
Choice D rationale:
There is no established increased risk of preeclampsia in clients with coarctation of the aorta.
A nurse is providing teaching to a young adult client who has fibrocystic breast condition. Which of the following instructions should the nurse include in the teaching?
A. Wear a supportive bra 24 hr a day.
While wearing a supportive bra is generally advisable, wearing it 24 hours a day is not necessary and may cause discomfort.
B. Perform a breast self-exam 1 week before menstruation.
Performing a breast self-exam 1 week after menstruation is recommended for individuals with fibrocystic breast condition. Hormonal changes during the menstrual cycle can affect breast tissue, and examining the breasts when they are less likely to be affected by hormonal fluctuations can provide a more accurate baseline for self-examination.
C. Have a mammogram every 4 years.
Mammograms are recommended more frequently than every 4 years, especially for those with fibrocystic breast condition or other risk factors.
D. Increase caffeine intake.
Increasing caffeine intake can exacerbate symptoms of fibrocystic breast condition. Caffeine is known to contribute to breast pain and tenderness.
Full Explanation
Choice A rationale:
While wearing a supportive bra is generally advisable, wearing it 24 hours a day is not necessary and may cause discomfort.
Choice B rationale:
Performing a breast self-exam 1 week after menstruation is recommended for individuals with fibrocystic breast condition. Hormonal changes during the menstrual cycle can affect breast tissue, and examining the breasts when they are less likely to be affected by hormonal fluctuations can provide a more accurate baseline for self-examination.
Choice C rationale:
Mammograms are recommended more frequently than every 4 years, especially for those with fibrocystic breast condition or other risk factors.
Choice D rationale:
Increasing caffeine intake can exacerbate symptoms of fibrocystic breast condition. Caffeine is known to contribute to breast pain and tenderness.