A patient who was walking in the woods disturbed a beehive, was stung, and was taken to the emergency department immediately due to allergies to bee stings. Which of the ff. symptoms would the nurse expect to see upon admission of this patient? i.Pallor around the sting bites iv. Retinal hemorrhage ii.Numbness and tingling in the extremities v. Tachycardia iii.Respiratory stridor vi. Dyspnea

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Question 1 of 5

A patient who was walking in the woods disturbed a beehive, was stung, and was taken to the emergency department immediately due to allergies to bee stings. Which of the ff. symptoms would the nurse expect to see upon admission of this patient? i.Pallor around the sting bites iv. Retinal hemorrhage ii.Numbness and tingling in the extremities v. Tachycardia iii.Respiratory stridor vi. Dyspnea

Correct Answer: B

Rationale: The nurse would expect to see respiratory stridor (iii), tachycardia (v), and dyspnea (vi) upon admission of the patient who was stung by a bee, particularly if the patient has allergies to bee stings. These symptoms are indicative of an allergic reaction, which can progress to anaphylaxis in severe cases. Symptoms such as pallor around the sting bites (i), retinal hemorrhage (iv), and numbness and tingling in the extremities (ii) are not typically associated with an allergic reaction to a bee sting.

Question 2 of 5

A client with autoimmune thrombocytopenia and a platelet count of 8,000/ul develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery-this will go away on its own". In considering her response to the client, the nurse must depend on the ethical principle of:

Correct Answer: C

Rationale: The ethical principle most relevant in this situation is autonomy. Autonomy refers to a person's right to make decisions about their own care and treatment. In this case, the client is expressing her wish to avoid surgery and believes her condition will improve on its own. It is important for the nurse to respect the client's autonomy and involve her in the decision-making process regarding her treatment. The nurse should provide information, support, and guidance to help the client make an informed decision that aligns with her values and preferences. While the nurse can provide education and encourage the client to consider the physician's recommendation, ultimately the decision should respect the client's autonomy.

Question 3 of 5

A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?

Correct Answer: B

Rationale: Antacids can interfere with the absorption of iron from ferrous sulfate. Therefore, it is important to take these medications at least 2 hours apart to ensure proper absorption of the iron supplement. Taking them together can reduce the effectiveness of the ferrous sulfate therapy in treating the iron deficiency. It is not necessary to avoid taking an antacid altogether, but timing is crucial to optimize the benefits of both medications.

Question 4 of 5

A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:

Correct Answer: C

Rationale: A client with HIV undergoing intradermal anergy testing with Candida and mumps antigens is suspected to be immunodeficient, making them unable to mount a normal skin response to these antigens. In an immunodeficient individual, the immune system is weakened, leading to a lack of response when exposed to these antigens. A lack of induration or reaction in the 3 days following the test suggests that the client's immune system is not able to mount a normal response, indicating immunodeficiency. The absence of a reaction does not necessarily indicate lack of exposure (Option A), presence of antibodies (Option B), or the absence of allergies (Option D), but rather points to a compromised immune system in an individual with HIV.

Question 5 of 5

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100mcg IM daily. Which substance influences Vitamin B12 absorption?

Correct Answer: A

Rationale: Intrinsic factor is a glycoprotein produced by the parietal cells of the stomach. It is essential for the absorption of vitamin B12 in the intestine. Vitamin B12 binds to intrinsic factor in the stomach, forming a complex that is absorbed in the ileum of the small intestine. Without intrinsic factor, vitamin B12 absorption is significantly impaired, leading to conditions like pernicious anemia, which is a type of megaloblastic anemia caused by vitamin B12 deficiency. By administering cyanocobalamin (Betalin-12) intramuscularly, the need for intrinsic factor in the absorption process is bypassed, which is necessary in cases where intrinsic factor production or function is disrupted.

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