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Questions 158

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Question 1 of 5

The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?

Correct Answer: B

Rationale: Pernicious anemia, caused by vitamin B12 deficiency, leads to neurological symptoms like numbness and tingling due to nerve demyelination. The other symptoms are common in various anemias.

Question 2 of 5

The nurse is caring for a client with a history of a pulmonary embolism. The client is receiving Heparin. The nurse should monitor the client for:

Correct Answer: A

Rationale: Heparin, an anticoagulant, increases bleeding risk, including bleeding gums. Hypertension, tachypnea, and fever are not directly related to heparin therapy.

Question 3 of 5

The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:

Correct Answer: A

Rationale: Ménière’s disease affects the inner ear, causing vertigo, tinnitus, and hearing loss due to fluid imbalance.

Question 4 of 5

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Correct Answer: B

Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Question 5 of 5

The client is admitted with a diagnosis of molar pregnancy. Which intervention is most appropriate?

Correct Answer: A

Rationale: Molar pregnancy involves abnormal trophoblastic tissue and no viable fetus often causing vaginal bleeding. Monitoring for bleeding is critical.
Tocolytics cesarean delivery and fetal monitoring are not indicated.

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