What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?
diarrhea
diaphoresis
fainting
vomiting
The Correct Answer is C
(a) Diarrhea: Diarrhea is an abnormal gastrointestinal response characterized by frequent, loose, or watery stools. It can be caused by infections, medications, or underlying gastrointestinal disorders. Pallor, or paleness of the skin, typically does not directly lead to diarrhea unless there are specific underlying conditions affecting both circulation and gastrointestinal function.
(b) Diaphoresis: Diaphoresis refers to excessive sweating, which can occur due to sympathetic nervous system activation, fever, or anxiety. While diaphoresis may be associated with conditions causing increased sympathetic activity, it is not directly related to pallor, which indicates reduced blood flow to the skin.
(c) Fainting: Pallor is often a sign of decreased blood flow to the skin, indicating potential hypoperfusion. If severe, this reduced circulation can lead to fainting (syncope) due to inadequate blood supply to the brain. Therefore, after noting pallor, the nurse should be prepared to manage the client for potential fainting episodes by ensuring safety and providing appropriate interventions.
(d) Vomiting: Vomiting is the forceful expulsion of stomach contents through the mouth and can be caused by various factors such as gastrointestinal irritation, infection, or systemic illnesses. Pallor does not directly cause vomiting, although severe systemic conditions affecting circulation could potentially lead to nausea and vomiting as part of a broader clinical picture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
(a) "Your metabolism is slowing down.":
Hypothyroidism leads to a decrease in the production of thyroid hormones, which are critical in regulating metabolism. With lower levels of these hormones, the body's metabolic rate decreases, resulting in reduced calorie burning and subsequent weight gain. This explanation directly addresses the underlying cause of weight gain in hypothyroidism.
(b) "You should be exercising for longer periods of time.":
While exercise is beneficial for overall health and can help manage weight, it does not directly address the reason for weight gain in hypothyroidism. The primary issue is the slowed metabolism due to thyroid hormone deficiency, not a lack of exercise.
(c) "You could be making healthier food choices.":
Although diet plays a role in weight management, this response does not explain the root cause of weight gain in hypothyroidism. The condition itself slows metabolism, leading to weight gain even if dietary habits remain unchanged.
(d) "You are retaining fluid.":
Fluid retention can occur in hypothyroidism but is not the primary reason for weight gain in this condition. The main cause is a decreased metabolic rate, which leads to the accumulation of body fat. Fluid retention might contribute to some weight gain, but it is not the best explanation in this context.
Correct Answer is D
Explanation
A) Electrical cords are placed along the walls: While it is important to ensure that electrical cords are safely managed, cords placed along the walls are less likely to pose a tripping hazard compared to those that are left loose or run across walking paths. This setup, in itself, is generally not a significant safety risk if managed properly.
B) Handrails are present in the bathroom: Handrails in the bathroom are actually a safety feature, not a risk. They provide necessary support for older adults with decreased vision or mobility issues, helping to prevent falls when using the toilet or getting in and out of the bathtub or shower.
C) Uses a microwave for cooking: Using a microwave for cooking is generally considered safe for individuals with decreased vision, as it minimizes the risk of burns and other injuries associated with using a stove or oven. The microwave can be a safer cooking method if the client is familiar with its operation.
D) Scatter rugs are present in the kitchen: Scatter rugs are a significant safety risk, especially for older adults with decreased vision. These rugs can easily cause trips and falls, leading to potentially serious injuries. Removing scatter rugs or securing them with non-slip backing can help mitigate this risk and create a safer home environment.
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