Extract:

Question 1 of 5

The nurse is teaching a client and his family about the client's new diagnosis of hemochromatosis. Which of the following details should the nurse include?

Correct Answer: B,D

Rationale: Hemochromatosis is a genetic disorder caused by HFE gene mutations, not an autoimmune condition. Heterozygous individuals rarely develop the disease, as two mutated genes are typically required. Homozygous individuals have the disease, not just carriers. Men are at greater risk due to higher iron accumulation (women lose iron via menstruation). These points should be included in teaching.

Question 2 of 5

Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube?

A. Electrical burns of the hands and arms causing arrhythmias. B. Thermal burns to the head, face, and airway resulting in hypoxia. C. Chemical burns on the chest and abdomen. D. Secondhand smoke inhalation.

Correct Answer: B

Rationale: Thermal burns to the head, face, and airway can cause swelling and obstruction, leading to hypoxia and requiring airway management like endotracheal intubation or tracheostomy.

Question 3 of 5

Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?

A. To promote oxygen intake. B. To strengthen the diaphragm. C. To strengthen the intercostal muscles. D. To promote carbon dioxide elimination.

Correct Answer: D

Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.

Question 4 of 5

An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

A. Apply lanolin or petroleum jelly to intact skin B. Encourage a reduced-calorie, reduced-fat diet C. Inspect the involved areas daily for new ulcerations D. Instruct the client to limit activities of daily living (ADLs) E. Use an electric razor to shave

Correct Answer: B,C,E

Rationale: Rationales:
B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow.
C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin.
A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion.
D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.

Question 5 of 5

An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the client should be made to be removed for which of the following complications?

A. Vertigo. B. Bell's palsy. C. Hypoventilation. D. Loss of gag reflex.

Correct Answer: C

Rationale: Posterior packing can obstruct the airway, leading to hypoventilation, a serious complication. Vertigo, Bell's palsy, and loss of gag reflex are not directly associated with posterior packing.