A nurse is assessing a client who has iron-deficiency anemia. Which of the following findings should the nurse expect?

Reports intolerance to heat

Develops bradycardia after eating

Has a friction rub on auscultation

Displays dyspnea while walking

Answer and Explanation

The Correct Answer is D

A) Reports intolerance to heat: Intolerance to heat is more commonly associated with conditions like hyperthyroidism rather than iron-deficiency anemia. Individuals with iron-deficiency anemia often experience fatigue and cold intolerance due to decreased oxygen-carrying capacity of the blood.

B) Develops bradycardia after eating: Bradycardia (slow heart rate) is not typically associated with iron-deficiency anemia. Anemia usually causes an increased heart rate (tachycardia) as the body tries to compensate for reduced oxygen delivery.

C) Has a friction rub on auscultation: A friction rub is a sound heard on auscultation associated with pericarditis, an inflammation of the pericardium, and is not a typical finding in iron-deficiency anemia. Anemia primarily affects the blood and does not usually cause inflammation of the heart lining.

D) Displays dyspnea while walking: Dyspnea, or shortness of breath, is a common symptom of iron-deficiency anemia, particularly with exertion. This occurs because the reduced hemoglobin levels result in decreased oxygen delivery to tissues, making physical activities more challenging and causing breathlessness.

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Correct Answer is B

Explanation

A) Fever: Myxedema coma is characterized by hypothermia rather than fever. The client with myxedema coma may experience a lowered body temperature, reflecting the severe hypothyroidism associated with this condition.

B) Hypernatremia: Hypernatremia, or elevated sodium levels, is a common finding in myxedema coma. This occurs due to impaired renal function and decreased aldosterone levels, leading to an imbalance in electrolytes, including sodium.

C) Hypertension: Typically, myxedema coma presents with hypotension rather than hypertension. The condition is associated with decreased cardiac output and low blood pressure, not elevated blood pressure.

D) Hypoglycemia: In myxedema coma, hypoglycemia is not typically expected. Instead, patients may experience hypoglycemia due to reduced metabolic rate and decreased glycogen stores. However, hyperglycemia is more commonly observed in other endocrine disorders, not specifically in myxedema coma.

A. Maintain the client on bed rest for 48 hr following surgery. B. Check the tubing for kinks and blood clots at least every 2 hr. C. Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate. D. Remove the catheter if the client reports severe bladder spasms.

Correct Answer is B

Explanation

A) Maintain the client on bed rest for 48 hr following surgery: While some bed rest is recommended initially post-surgery, maintaining bed rest for 48 hours is excessive and can increase the risk of complications like deep vein thrombosis. Early mobilization is generally encouraged to enhance recovery.

B) Check the tubing for kinks and blood clots at least every 2 hr: Regularly checking the catheter tubing for kinks and blood clots is essential to ensure the continuous flow of urine and prevent catheter blockage. This can help in reducing the risk of complications such as bladder distension and urinary retention.

C) Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate: Continuous bladder irrigation is often done post-TURP to prevent clot formation, but 5% dextrose in Ringer's lactate is not the recommended solution. Typically, normal saline is used to minimize the risk of electrolyte imbalance and maintain the correct osmolarity.

D) Remove the catheter if the client reports severe bladder spasms: Severe bladder spasms can occur post-TURP, but removing the catheter is not the immediate solution. The catheter is necessary for drainage and should be managed with antispasmodic medications or adjusting the irrigation flow rather than removal.

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A nurse is assessing a client who has iron-deficiency anemia. Which of the following findings should the nurse expect?

Nursing Test Bank

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