Exhibits

For each statement, click to specify whether the statement is consistent with iron deficiency anemia, vitamin B12 deficient anemia, or folic acid deficient anemia.

Each row must have at least one, but may have more than one, response option selected.

Decreased hemoglobin and hematocrit levels

Uptake often impeded by medications

Often associated with chronic alcoholism

Can be caused by malabsorption syndrome

Result of dietary deficiency

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B,C"},"E":{"answers":"A,B,C"}}

-   Decreased hemoglobin and hematocrit levels: Consistent with iron deficiency anemia, vitamin B12 deficient anemia, and folic acid deficient anemia. Iron deficiency anemia results from
inadequate iron stores, while vitamin B12 deficient anemia and folic acid deficient anemia are characterized by inadequate levels of these respective vitamins, all of which contribute to decreased hemoglobin and hematocrit levels.
-   Uptake often impeded by medications: Consistent with iron deficiency anemia and vitamin B12 deficient anemia. Iron absorption can be affected by certain medications, such as proton pump
inhibitors or antacids, which can hinder iron uptake. Vitamin B12 deficiency can result from medications that interfere with its absorption, such as proton pump inhibitors or metformin.

-   Often associated with chronic alcoholism: Consistent with vitamin B12 deficient anemia. Chronic alcoholism can lead to vitamin B12 deficiency due to poor dietary intake,
malabsorption, or liver dysfunction associated with excessive alcohol consumption.

- Can be caused by malabsorption syndrome: Consistent with vitamin B12 deficient anemia and folic acid deficient anemia. Malabsorption syndromes, such as celiac disease or Crohn's disease, can impair the absorption of both vitamin B12 and folic acid from the gastrointestinal tract,
leading to deficiencies.

- Result of dietary deficiency: Consistent with iron deficiency anemia, vitamin B12 deficient anemia, and folic acid deficient anemia. Iron deficiency anemia results from inadequate dietary intake of iron-rich foods, while vitamin B12 deficient anemia and folic acid deficient anemia stem from insufficient dietary intake of foods rich in these respective vitamins.

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Correct Answer is B

Explanation

A. Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B. Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D. Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

A. Tell the UAP to use a different sphygmomanometer. B. Ask the UAP to take the blood pressure in the other arm. C. Administer a PRN antianxiety medication. D. Review the client's serum calcium level.

Correct Answer is D

Explanation

A: Using a different sphygmomanometer would not address the underlying cause of the spasms, which is likely not related to the equipment itself.
B: Taking the blood pressure in the other arm may avoid the spasms temporarily, but it does not address the potential underlying medical issue causing the spasms.
C: Administering an antianxiety medication is not indicated as the spasms are not necessarily related to anxiety; they could be a sign of a physiological condition.
D: Reviewing the client's serum calcium level is the most appropriate action. The spasms described are indicative of Trousseau's sign, which is associated with hypocalcemia. Hypocalcemia can cause increased neuromuscular excitability, leading to spasms. It is important to identify and treat the underlying cause of the spasms, which in this case could be a calcium deficiency.

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Exhibits For each statement, click to specify whether the statement is consistent with iron deficiency anemia, vitamin B12 deficient anemia, or folic acid deficient anemia. Each row must have at least one, but may have more than one, response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Correct Answer is D

Explanation

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

Which laboratory test results should the nurse monitor in a client who has end-stage renal disease (ESRD)?

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Exhibits The nurse should place the client in a position to promote

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Exhibits

For each statement, click to specify whether the statement is consistent with iron deficiency anemia, vitamin B12 deficient anemia, or folic acid deficient anemia.

Each row must have at least one, but may have more than one, response option selected.