NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
The nurse devises a teaching plan for the client with aplastic anemia. Which of the following is the most important concept to teach for health promotion and maintenance?
Correct Answer: B
Rationale: Aplastic anemia is characterized by bone marrow failure, leading to low blood cell counts and increased risk of infection due to neutropenia. The most important health promotion strategy is to avoid exposure to infections, as infections can be life-threatening in these clients. While nutrition, stress management, and sleep are important, infection prevention is the priority.
Question 2 of 5
When monitoring a client who is receiving t-PA, the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
Correct Answer: A
Rationale: Reperfusion from t-PA can cause arrhythmias due to myocardial irritability as blood flow is restored, necessitating resuscitation equipment.
Question 3 of 5
An 82-year-old female has several ecchymotic areas on her left arm. The nurse should further assess the client for:
Correct Answer: C
Rationale: Aging increases capillary fragility and permeability, leading to easy bruising (ecchymosis). While elder abuse is possible, capillary fragility is the most likely cause in this context.
Question 4 of 5
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
Question 5 of 5
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will:
Correct Answer: C
Rationale: Developing cognition is not realistic, as MS can cause cognitive decline that is not typically reversible. Improving mobility, strength, and mood are achievable with therapy and support.