A patient is admitted with a 2-month history of fatigue, SOB, pallor, and dizziness. The patient is diagnosed with idiopathic autoimmune haemolytic anemia. On reviewing the laboratory results, the nurse notes which of the following that confirms this diagnosis?

Correct Answer: A

Rationale: The correct answer is A: RBC fragments. In idiopathic autoimmune hemolytic anemia, the immune system attacks and destroys red blood cells, leading to hemolysis. The presence of RBC fragments in the blood smear confirms this diagnosis as it indicates mechanical damage to RBCs. Explanation: 1. RBC fragments (schistocytes) are a hallmark of hemolysis, seen in conditions like autoimmune hemolytic anemia. 2. Microcytic, hypochromic RBCs (Choice B) are typically seen in iron deficiency anemia, not autoimmune hemolytic anemia. 3. Macrocytic, normochromic RBCs (Choice C) are characteristic of megaloblastic anemias like vitamin B12 deficiency, not autoimmune hemolytic anemia. 4. Hemoglobin molecules (Choice D) are not directly indicative of autoimmune hemolytic anemia; the presence of free hemoglobin in the blood would suggest intrav

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.

Correct Answer: C

Rationale: The correct answer is C. In hypothyroidism, the thyroid gland is underactive, leading to symptoms like puffiness of the face and hands due to fluid retention. This occurs as a result of decreased metabolism. Options A and B are symptoms of hyperthyroidism, where the thyroid gland is overactive. Option D is a symptom of goiter, which is thyroid gland swelling, not specific to hypothyroidism. Therefore, the correct answer is C based on the characteristic symptoms of hypothyroidism.

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. This type of assessment approach involves starting with a broad overview of the patient's condition and then narrowing down to specific details. In this scenario, the nurse begins by examining the surgical dressing, which is a specific aspect of the patient's condition, after which they can proceed to gather more detailed information about the drainage, wound healing, and any associated symptoms. This approach allows the nurse to systematically assess the patient's postoperative status and identify any potential issues. A: Gordon’s Functional Health Patterns is a comprehensive framework for organizing patient data, but it does not specifically address the sequence of assessment in this scenario. B: Activity-exercise pattern assessment focuses on the patient's activity level and exercise habits, which is not the primary concern in this situation. D: Problem-oriented assessment involves identifying and addressing specific health problems, but it does not capture the systematic progression from general to specific assessment as seen in this scenario.

Correct Answer: B

Rationale: The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal. Incorrect choices: A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull. C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction. D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.

Correct Answer: D

Rationale: The correct answer is D: A painless mass in the breast. This is the primary sign of breast cancer because most breast cancers present as painless lumps or masses. This is due to the abnormal growth of cells forming a tumor. Other choices (A, B, C) are also signs of breast cancer, but they are not as common or primary as the presence of a painless mass. A bloody discharge from the nipple (A) can be a sign of a benign condition or cancer, but it is not the most common presentation. Nipple retraction (B) and dimpling of the skin over the lesion (C) can also be signs of breast cancer, but they usually occur in later stages of the disease. Therefore, the presence of a painless mass in the breast is the primary sign that should raise suspicion for breast cancer.

Correct Answer: D

Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.

Correct Answer: C

Rationale: Step-by-step rationale: 1. INH (Isoniazid) can lead to peripheral neuropathy due to vitamin B6 deficiency. 2. Pyridoxine is vitamin B6, which helps prevent neuropathy. 3. Supplementing with pyridoxine can counteract the deficiency caused by INH. 4. Thus, option C, supplementing the diet with pyridoxine, is the correct choice. Summary: - Option A is incorrect as a low cholesterol diet does not address the vitamin B6 deficiency. - Option B is incorrect as excessive bed rest does not prevent neuropathy. - Option D is incorrect as sun exposure is not related to the prevention of peripheral neuropathy.