A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

Itching, rash, and jaundice

Night sweats, weight loss, and diarrhea

Dyspnea, tachycardia, and pallor

Nausea, vomiting, and anorexia

Answer and Explanation

The Correct Answer is C

Reasoning:

Choice A reason: Itching, rash, and jaundice are not typical of iron deficiency anemia. Jaundice suggests hemolysis or liver disease, and itching or rash may indicate allergic or dermatologic conditions. Iron deficiency causes reduced hemoglobin, leading to oxygen delivery issues, not these symptoms, making this incorrect.

Choice B reason: Night sweats, weight loss, and diarrhea suggest systemic conditions like malignancy or infection, not iron deficiency anemia. These symptoms are unrelated to low iron, which primarily causes fatigue and pallor due to reduced hemoglobin and oxygen-carrying capacity, not inflammatory or gastrointestinal symptoms.

Choice C reason: Dyspnea, tachycardia, and pallor are classic findings in iron deficiency anemia. Low hemoglobin reduces oxygen delivery, causing dyspnea and tachycardia as the body compensates. Pallor results from decreased red blood cell mass, reflecting the anemia’s impact on tissue oxygenation and circulation.

Choice D reason: Nausea, vomiting, and anorexia are not primary features of iron deficiency anemia. These gastrointestinal symptoms may occur with iron supplementation side effects or other conditions, but anemia itself causes fatigue, pallor, and dyspnea due to low hemoglobin, not digestive disturbances.

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Correct Answer is B

Explanation

Reasoning:

Choice A reason: Aspiration precautions are important in head injury to prevent pneumonia, particularly if consciousness is impaired, but they are not specific seizure prophylactic measures. Seizures require anticonvulsants to prevent neuronal hyperexcitability, making aspiration precautions a secondary concern unrelated to seizure prevention.

Choice B reason: Anticonvulsant medications, initiated early (e.g., day two), are standard for seizure prophylaxis in head injury. Trauma can cause cortical irritation, increasing seizure risk. Drugs like levetiracetam stabilize neuronal activity, preventing seizures, which could worsen brain injury or ICP, making this the primary measure.

Choice C reason: Intubation and ventilator support are used for severe head injuries with compromised airway or breathing but are not seizure prophylaxis. Seizures are managed with anticonvulsants, as mechanical ventilation does not address neuronal excitability, making this inappropriate for seizure prevention.

Choice D reason: Antiemetic medications manage nausea but are not seizure prophylactic measures. While vomiting may occur post-head injury, it does not prevent seizures, which result from cortical irritability. Anticonvulsants directly target seizure risk, making antiemetics irrelevant to this specific intervention goal.

A. Explain that the client’s physical changes are a result of excessive corticosteroids B. Offer clothing or bedding that’s cool and comfortable C. Explain the rationale for increasing salt and fluid intake in times of illness, increased stress, and very hot weather D. Suggest a high-carbohydrate, low-protein diet

Correct Answer is A

Explanation

Reasoning:

Choice A reason: Explaining that physical changes in Cushing’s syndrome, like moon face and weight gain, result from excessive corticosteroids helps the client understand their condition. Cortisol excess causes fat redistribution and metabolic changes, and education promotes adherence to treatment and coping with body image changes, improving psychological and physical management.

Choice B reason: Offering cool, comfortable clothing or bedding addresses symptoms like heat intolerance in Cushing’s syndrome due to cortisol’s metabolic effects. However, it is less critical than education about the condition, as it does not address the underlying cause or promote understanding and adherence to long-term management strategies.

Choice C reason: Increasing salt and fluid intake is appropriate for Addison’s disease, not Cushing’s syndrome, where cortisol’s mineralocorticoid effects cause fluid retention and hypertension. This intervention could worsen fluid overload and hyponatremia, making it inappropriate and potentially harmful for managing Cushing’s syndrome symptoms.

Choice D reason: A high-carbohydrate, low-protein diet is not recommended for Cushing’s syndrome. Cortisol excess causes protein catabolism and hyperglycemia, so a balanced diet with adequate protein supports muscle maintenance and glucose control. This dietary suggestion does not address the metabolic needs of the condition.

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A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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