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: B

Rationale: The correct answer is B. A semiprivate room with one or two consistent caregivers is the most therapeutic setting for an agitated head-injured patient. Here's the rationale: 1. Consistency: Having one or two consistent caregivers provides the patient with a stable and familiar environment, which can help reduce agitation. 2. Privacy: A semiprivate room offers more privacy compared to a day room or a ward, which can help minimize external stimuli and promote relaxation. 3. Individualized care: In a semiprivate room, caregivers can focus more on the specific needs of the patient, leading to better management of agitation. 4. Reduced distractions: Being in a semiprivate room minimizes distractions and noise, which can be overwhelming for an agitated head-injured patient. Summary: A, C, and D are incorrect because they do not offer the same level of consistency, privacy, individualized care, and reduced distractions as a semiprivate room with one

Correct Answer: B

Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5-FU). Fluorouracil is a commonly used chemotherapy drug for treating advanced liver cancer. It works by inhibiting the growth of cancer cells. This drug is specifically effective in targeting rapidly dividing cells, which is a characteristic of cancer cells. Fluorouracil is often used in combination with other chemotherapy drugs to improve treatment outcomes. Summary of other choices: A: Fluoxymesterone (Halotestin) - This is an androgen hormone used to treat certain types of breast cancer, not liver cancer. C: Tamoxifen (Nolvadex) - This is a hormonal therapy drug used in breast cancer, not liver cancer. D: Megestrol (Megace) - This is a hormonal therapy drug used for certain types of cancers, but not typically for liver cancer.

Correct Answer: C

Rationale: The correct answer is C: Avoiding the use of carbonated beverages. Carbonated beverages often have high sodium content, which can contribute to increased sodium intake. By avoiding these beverages, the client can significantly reduce their sodium consumption. Explanation: 1. Carbonated beverages often contain added sodium for flavor enhancement. 2. By avoiding carbonated beverages, the client eliminates a significant source of hidden sodium in their diet. 3. This dietary practice directly targets reducing sodium intake without compromising other nutritional aspects of the diet. Summary of other choices: A: Increasing the use of dairy products - Dairy products do not necessarily impact sodium intake significantly. B: Using an artificial sweetener in coffee - Artificial sweeteners do not contribute to sodium intake. D: Using catsup for cooking and flavoring food - Catsup is high in sodium and would not help in reducing sodium intake.

Correct Answer: C

Rationale: The correct answer is C: Muscle weakness. Metolazone is a diuretic that can lead to low potassium levels, causing muscle weakness. Instructing the patient to report muscle weakness is crucial to prevent any potential serious complications. Numb hands, gastrointestinal distress, and nightmares are not commonly associated with metolazone and do not pose as immediate risks as muscle weakness does. It is essential to prioritize the most critical side effect to ensure the patient's safety and well-being.

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: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being. Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.

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: D

Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.