Exhibits
Drag from Word Choices to complete the sentence.
According to the lab values, the client has
The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"H","dropdown-group-3":"D"}
Rationale for Correct Choices:
- Anemia: The lab values indicate that the client’s hemoglobin and hematocrit are lower than normal, suggesting anemia. Anemia in this case is likely due to blood loss from the trauma, as the client has internal hemorrhaging, with blood noted in the peritoneum.
- Blood loss: The client’s abdominal trauma, with liver and spleen lacerations and blood in the peritoneum, is a clear indicator of significant internal bleeding. This blood loss is directly responsible for the anemia seen in the lab results.
- Hemodilution from intravenous fluids: The client is receiving IV fluids at a rate of 100 mL/hr, which can dilute the blood and artificially lower hematocrit and hemoglobin levels. This is a common effect when fluids are given in large amounts, as the fluid increases plasma volume without immediately increasing red blood cells.
Rationale for Incorrect Choices:
- Acidosis: Acidosis typically presents with changes in blood pH and respiratory or renal compensation, which is not indicated by the client's lab results or current status. There are no signs of metabolic or respiratory acidosis in the current clinical picture.
- Rh factor sensitization: Rh factor sensitization usually occurs during pregnancy when Rh-negative mothers develop antibodies against Rh-positive fetal blood cells. This is unrelated to the client’s trauma and lab findings, which focus on anemia.
- Hypovolemia: Hypovolemia is more directly related to the blood loss and the hemodilution effect from intravenous fluid administration, making it a contributing but less specific factor in the anemia diagnosis.
- Disseminated intravascular coagulation (DIC): DIC is characterized by widespread clotting followed by bleeding. There is no evidence of abnormal clotting or bleeding issues in the lab results or clinical presentation, such as abnormal coagulation studies.
- Pregnancy: Pregnancy is not applicable in this case as the client's history does not mention any signs or symptoms of pregnancy. Anemia in this patient is related to trauma-induced blood loss and subsequent hemodilution, not pregnancy-related causes.
- Clotting cascade: While it is relevant to conditions like DIC or bleeding disorders, it does not directly explain the client's low hemoglobin or hematocrit. The lab results are more consistent with blood loss and fluid resuscitation.
- Blood administration: There is no mention of the client receiving blood products. While blood transfusion might be needed given the blood loss, there is no current indication from the lab results that blood administration has occurred or is required at this point.
- Immune response: An immune response is typically seen in infections or allergic reactions. The client’s current clinical condition and lab results do not suggest an infection or immune response but rather trauma-related blood loss and fluid effects.
- Hypoventilation: Hypoventilation typically leads to respiratory acidosis or elevated CO2 levels, but the client is intubated and on mechanical ventilation, with no indication of respiratory distress or acidosis.
- Hypoxia: Although trauma patients may experience hypoxia, the client’s oxygen saturation is 100%, and there is no indication of respiratory distress or hypoxia in the lab results. The anemia is more related to blood loss rather than a lack of oxygen in the tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Offer the client to move to a quiet room first: Changing the environment may reduce distractions, but it does not directly support the client’s immediate attempt to communicate. The priority is to respond to the client’s active effort to speak in the moment.
B. Allow the client time to complete her sentence: Allowing extra time promotes autonomy, reduces frustration, and respects the communication process for clients with aphasia. It gives the client space to formulate thoughts without pressure or interruption, which supports language recovery and expression.
C. Pull up a chair and sit quietly with the client: Sitting quietly can offer emotional support, but it may be perceived as passive when the client is actively trying to communicate. The nurse should take a facilitative role by giving the client time to speak, rather than only offering silent presence.
D. Provide a list of phrases to express herself properly: Providing phrases may overwhelm or confuse the client, especially during spontaneous attempts to speak. Aphasia affects word retrieval, and prompting with choices may interrupt the client's cognitive effort.
Correct Answer is ["A","E"]
Explanation
Rationale for Correct Choices:
- The nurse assesses the client. The client reports he was able to sleep through the night:
Being able to sleep through the night suggests that the client’s pain is adequately managed, indicating progress in terms of pain control post-surgery or trauma care. - The left arm is warm to touch: The warmth of the left arm indicates that circulation has improved from initially cool to touch. This is a positive sign, as it suggests that there are no significant vascular complications following the fracture or trauma.
- The client's left shoulder and collarbone are symmetric: Symmetry of the shoulder and collarbone suggests that there is no new displacement or injury to the bones post-trauma or surgery. This is a good sign indicating that the fracture is properly stabilized.
Rationale for Incorrect Choices:
- The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers: The numbness, tingling, and inability to move his fingers may indicate nerve involvement, which could be a sign of complications such as nerve compression or injury due to the fracture.
- The client reports mild nausea and has no desire to eat breakfast: Mild nausea is expected after anesthesia or pain medications, but continued lack of appetite or worsening nausea may signal complications, such as a delayed reaction to anesthesia or a side effect from medication, which should be monitored.
- There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage: While some blood may be expected post-surgery or after trauma, a blood stain of this size should be evaluated for any indication of active bleeding or complications such as hematoma formation. It may not be expected if the bleeding had been controlled.
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