A clinic nurse is working with a client who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the client's disease?

Follow the trends of the client's hematocrit.

Document the color of the client's palms and face during each visit.

Document the client's response to erythropoietin injections.

Follow the client's erythrocyte sedimentation rate over time.

Answer and Explanation

The Correct Answer is A

A. Follow the trends of the client's hematocrit: This is the most reliable way to gauge the course of polycythemia vera. The condition is characterized by an increase in red blood cell mass, and tracking changes in hematocrit levels helps assess disease progression and the effectiveness of treatment.

B. Document the color of the client's palms and face during each visit: While polycythemia vera can cause ruddy complexion due to increased red blood cell count, changes in the color of the palms and face are not a consistent or reliable indicator of disease progression. Hematocrit levels are more direct measures.

C. Document the client's response to erythropoietin injections: Erythropoietin is not used in the treatment of polycythemia vera because the disease involves excess RBC production. Primary treatment focuses on reducing RBC count rather than increasing it with erythropoietin.

D. Follow the client's erythrocyte sedimentation rate over time: The erythrocyte sedimentation rate (ESR) measures inflammation but does not specifically reflect the status of polycythemia vera. Hematocrit is a more direct and specific measure of the disease’s progression.

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Correct Answer is B

Explanation

A. It is primarily transmitted through casual contact: HIV is not transmitted through contact such as shaking hands, hugging, or sharing drinks. This is a misconception; HIV requires direct contact with infected body fluids like blood, semen, vaginal fluids, and breast milk.

B. It is primarily transmitted through direct contact with infected body fluids: HIV is primarily transmitted through contact with infected body fluids, such as through unprotected sexual contact, sharing needles, or from mother to child during childbirth or breastfeeding.

C. It is primarily transmitted through accidental puncture wounds: While accidental puncture wounds can be a risk for healthcare workers, this is not the primary mode of HIV transmission. Most transmissions occur through sexual contact or sharing contaminated needles.

D. It is primarily transmitted through mosquitoes: HIV is not transmitted through mosquitoes or other insects. It is a blood-borne virus and does not survive or replicate in mosquitoes, making this a myth.

A. Copious oral secretions B. Hoarseness C. Stridor D. Sore throat

Correct Answer is C

Explanation

A. Copious oral secretions: Copious oral secretions may occur after the removal of the endotracheal tube, especially if the client is still recovering from anesthesia. While concerning, this is not as immediately dangerous as stridor and can often be managed with suctioning.

B. Hoarseness: Hoarseness is a common and expected finding after extubation. It may result from irritation of the vocal cords or the trauma caused by the endotracheal tube. This is generally not an urgent issue and can resolve over time.

C. Stridor: Stridor is a high-pitched, wheezing sound that indicates upper airway obstruction. It is a serious sign of respiratory distress and requires immediate intervention. Stridor can be caused by swelling or laryngeal injury after extubation and should be reported immediately.

D. Sore throat: A sore throat is a common side effect of endotracheal tube placement and is typically not a cause for immediate concern. It usually resolves within a few days and does not require urgent reporting unless accompanied by other alarming symptoms.

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A clinic nurse is working with a client who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the client's disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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