Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Signs of hemolytic anaemias include:
A. Red, sore tongue.
Choice A is wrong because a red, sore tongue is a sign of vitamin B12 deficiency anemia, not hemolytic anaemia.
B. Pica.
Choice B is wrong because pica is a craving for nonfood items, such as ice, dirt, or starch. It is a sign of iron deficiency anemia, not hemolytic anemia.
C. Splenomegaly and Jaundice.
Splenomegaly and jaundice are signs of hemolytic anemia, a disorder in which red blood cells are destroyed faster than they are made. Splenomegaly is an enlargement of the spleen, which may trap and destroy healthy red blood cells. Jaundice is a yellowing of the skin and eyes caused by the buildup of bilirubin, a waste product of hemoglobin breakdown.
D. Paresthesias.
Choice D is wrong because paresthesias are sensations of tingling, numbness, or prickling in the hands or feet. They are a sign of pernicious anemia, a type of vitamin B12 deficiency anemia, not hemolytic anemia. Normal ranges for red blood cell count are 4.5 to 5.9 million cells per microliter for men and 4.1 to 5.1 million cells per microliter for women. Normal ranges for hemoglobin are 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 grams per deciliter for women. Normal ranges for bilirubin are 0.1 to 1.2 milligrams per deciliter for adults.
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Full Explanation
Splenomegaly and jaundice are signs of hemolytic anemia, a disorder in which red blood cells are destroyed faster than they are made.
Splenomegaly is an enlargement of the spleen, which may trap and destroy healthy red blood cells. Jaundice is a yellowing of the skin and eyes caused by the buildup of bilirubin, a waste product of hemoglobin breakdown. Choice A is wrong because red, sore tongue is a sign of vitamin B12 deficiency anemia, not hemolytic anemia.
Choice B is wrong because pica is a craving for nonfood items, such as ice, dirt, or starch. It is a sign of iron deficiency anemia, not hemolytic anemia. Choice D is wrong because paresthesias are sensations of tingling, numbness, or prickling in the hands or feet. They are a sign of pernicious anemia, a type of vitamin B12 deficiency anemia, not hemolytic anemia.
Normal ranges for red blood cell count are 4.5 to 5.9 million cells per microliter for men and 4.1 to 5.1 million cells per microliter for women. Normal ranges for hemoglobin are 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 grams per deciliter for women. Normal ranges for bilirubin are 0.1 to 1.2 milligrams per deciliter for adults.
Similar Questions
A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress.
Which of the following manifestations should the nurse include?
A. Decreased blood pressure.
Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.
B. Bronchial airway constriction.
Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.
C. Hypoglycemia.
Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy. Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.
D. Dilated pupils.
This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.
Full Explanation
This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.
Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.
Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.
Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.
Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?
A. Fluid volume excess.
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be risk for deficient fluid volume.
B. Risk for infection.
nfection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
C. Ineffective thermoregulation.
Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
D. Pain.
Appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
Full Explanation
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.
Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism.
Which nursing intervention is done to prevent heat loss by conduction?
A. Closing doors and windows to prevent draft (current of air with motion).
Choice A is wrong because closing doors and windows to prevent draft (current of air with motion) would prevent heat loss by convection, not conduction. Convection is the transfer of heat from a body to moving molecules such as air or liquid.
B. Keeping a hat on the baby’s head.
Choice B is wrong because keeping a hat on the baby’s head would prevent heat loss by radiation, not conduction. Radiation is the transfer of heat from a body to the surroundings by electromagnetic waves.
C. Thoroughly drying infant after a bath.
Choice C is wrong because thoroughly drying infant after a bath would prevent heat loss by evaporation, not conduction. Evaporation is the process of liquid changing into gas and carrying away heat from the body surface.
D. Placing a warm blanket on the scale prior to obtaining baby’s weight.
This is because heat loss by conduction occurs when two objects with different temperatures come into direct contact with each other. The baby’s skin would lose heat to the cold scale by conduction if there was no warm blanket between them.
Full Explanation
This is because heat loss by conduction occurs when two objects with different temperatures come into direct contact with each other. The baby’s skin would lose heat to the cold scale by conduction if there was no warm blanket between them.
Choice A is wrong because closing doors and windows to prevent draft (current of air with motion) would prevent heat loss by convection, not conduction. Convection is the transfer of heat from a body to moving molecules such as air or liquid.
Choice B is wrong because keeping a hat on the baby’s head would prevent heat loss by radiation, not conduction. Radiation is the transfer of heat from a body to the surroundings by electromagnetic waves.
Choice C is wrong because thoroughly drying infant after a bath would prevent heat loss by evaporation, not conduction. Evaporation is the process of liquid changing into gas and carrying away heat from the body surface.