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Questions 158

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Question 1 of 5

A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is:

Correct Answer: C

Rationale: Massive transfusions can cause hypocalcemia due to citrate in stored blood binding with calcium, especially in rapid transfusions.

Question 2 of 5

A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:

Correct Answer: C

Rationale: Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B,
D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.

Question 3 of 5

Assessment of the client's skin reveals numerous café au lait spots over the trunk. These changes are associated with which diagnosis?

Correct Answer: B

Rationale: Café au lait spots are characteristic of neurofibromatosis a genetic disorder affecting nerve tissue. They are not associated with polycythemia vera thalassemia major or acoustic neuroma.

Question 4 of 5

A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:

Correct Answer: B

Rationale: Myxedema (severe hypothyroidism) causes weight gain, lethargy, slowed speech, and decreased respiratory rate due to slowed metabolism. The other options describe hyperthyroidism or mixed symptoms.

Question 5 of 5

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

Correct Answer: B

Rationale: Fetal heart tones detectable by Doppler around 10-12 weeks and consistently by 20 weeks are the most definitive sign of pregnancy. HCG uterine enlargement and breast changes are presumptive or probable signs.

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