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A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?

[Select All that Apply)

Mood changes

Mobility challenges

Shortness of breath

Sleep disturbance

Answer and Explanation

Correct Answer : A,B,C,D

A. Mood changes: Deficiency can cause neurological changes, including depression and mood swings.

B. Mobility challenges: Neuropathy and muscle weakness can lead to mobility issues.

C. Shortness of breath: Anemia from B12 deficiency reduces oxygen delivery, causing dyspnea.

D. Visual deficit: Neurological impairment from B12 deficiency can affect the optic nerve, leading to visual disturbances.

E. Sleep disturbance: This is not a typical manifestation of B12 deficiency and is more likely related to other factors.

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Correct Answer is ["A","C"]

Explanation

A. Hypotension: Hypotension is a common sign of hemorrhage. It occurs due to significant blood loss leading to decreased circulating blood volume and reduced cardiac output, which in turn lowers blood pressure. In the context of postoperative care, hypotension is a critical sign that may indicate internal bleeding.

B. Diaphoresis: Diaphoresis (excessive sweating) can be an autonomic response to acute blood loss and shock. The body tries to compensate for reduced blood volume and pressure by activating the sympathetic nervous system, which results in sweating as part of the body's effort to maintain perfusion to vital organs.

C. Tachypnea: Tachypnea (rapid breathing) is a compensatory mechanism in response to decreased oxygen delivery due to blood loss. The body increases respiratory rate to improve oxygen uptake and delivery to tissues, which is vital when there is reduced blood volume from hemorrhage.

D. Bradycardia: Bradycardia (slow heart rate) is not typically associated with hemorrhage. Instead, hemorrhage usually causes tachycardia (rapid heart rate) as the body attempts to maintain cardiac output and compensate for the loss of blood volume. Bradycardia could indicate other issues such as increased intracranial pressure or a vagal response but is not a common sign of acute hemorrhage.

E. Diarrhea: Diarrhea is not a sign of hemorrhage. It is more commonly associated with gastrointestinal issues such as infections, inflammatory bowel diseases, or reactions to medications. Hemorrhage typically affects cardiovascular parameters rather than causing gastrointestinal symptoms like diarrhea.

A. Notifying the provider B. Stopping the transfusion C. Covering the client with a blanket D. Assessing the client's skin for a rash

Correct Answer is B

Explanation

A. Notifying the provider: This is important but should be done after stopping the transfusion.

B. Stopping the transfusion. Chills and back pain during a blood transfusion can indicate a serious transfusion reaction, such as an acute hemolytic reaction. The priority action is to stop the transfusion immediately to prevent further complications

C. Covering the client with a blanket: This addresses the symptom of chills but does not address the potential life-threatening reaction.

D. Assessing the client's skin for a rash: This is part of the assessment for transfusion reactions but is not the priority compared to stopping the transfusion.

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A nurse is providing teaching to a client who has a vitamin B12 deficiency about the potential manifestations of their condition if it is left untreated. Which of the following manifestations should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage? [Select All that Apply)

Correct Answer is ["A","C"]

Explanation

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

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A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?