During assessment of a client diagnosed with severe anemia, the nurse notes pallor of the skin and mucous membranes. Which explanation is the best rationale for this finding?
Blood clots in the peripheral blood vessels
Decrease in bone marrow platelet production
Increase in the number of circulating reticulocytes
Redistribution of blood to the heart and brain
The Correct Answer is D
Choice A reason: Blood clots in the peripheral blood vessels are not a cause of anemia, but a complication of it. They may occur due to increased blood viscosity, reduced blood flow, or hypercoagulability. They may cause tissue ischemia, pain, and necrosis.
Choice B reason: Decrease in bone marrow platelet production is not a cause of anemia, but a result of it. It may occur due to bone marrow suppression, infiltration, or destruction. It may cause bleeding, bruising, and petechiae.
Choice C reason: Increase in the number of circulating reticulocytes is not a cause of anemia, but a sign of it. Reticulocytes are immature red blood cells that are released from the bone marrow to compensate for the loss of mature red blood cells. They indicate a regenerative response to anemia.
Choice D reason: Redistribution of blood to the heart and brain is a compensatory mechanism for anemia. It occurs to maintain adequate oxygen delivery to the vital organs. It causes vasoconstriction and shunting of blood away from the skin and mucous membranes, resulting in pallor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Colon cancer is the most likely disorder that the client is at risk to develop because it is a type of cancer that affects the large intestine, which is the part of the digestive tract that absorbs water and forms stool. Colon cancer can be caused by various factors, such as genetics, diet, or inflammation. Ulcerative colitis is a chronic inflammatory bowel disease that causes ulcers and inflammation in the inner lining of the colon and rectum, which are the last parts of the large intestine. Ulcerative colitis can increase the risk of colon cancer by causing DNA damage and abnormal cell growth in the colon.
Choice B reason: Crohn disease is not the most likely disorder that the client is at risk to develop because it is a different type of inflammatory bowel disease that causes inflammation and damage in any part of the digestive tract, from the mouth to the anus. Crohn disease can be caused by various factors, such as genetics, immune system, or bacteria. Ulcerative colitis and Crohn disease have some similar symptoms, such as diarrhea, abdominal pain, or weight loss, but they are not the same condition and do not increase the risk of each other.
Choice C reason: Lactase deficiency is not the most likely disorder that the client is at risk to develop because it is a condition where the body does not produce enough lactase, which is an enzyme that breaks down lactose, which is a sugar that is found in milk and dairy products. Lactase deficiency can cause symptoms such as bloating, gas, or diarrhea after consuming lactose. Lactase deficiency can be caused by various factors, such as genetics, age, or intestinal injury. Ulcerative colitis does not affect the production of lactase, but it can cause lactose intolerance, which is a condition where the body cannot digest lactose properly due to the inflammation and damage of the colon.
Choice D reason: Irritable bowel syndrome is not the most likely disorder that the client is at risk to develop because it is a functional disorder that affects the movement and sensitivity of the bowel, causing symptoms such as abdominal pain, cramping, or constipation. Irritable bowel syndrome can be triggered by various factors, such as stress, food, or hormones. Irritable bowel syndrome does not cause inflammation or damage to the bowel, unlike ulcerative colitis, and it does not increase the risk of colon cancer.
Correct Answer is C
Explanation
Choice A reason: Increased serum hydrostatic pressure is not the best explanation for the edema because it is caused by fluid overload, not malnutrition. Fluid overload can result from heart failure, kidney failure, or excessive fluid intake.
Choice B reason: Increased kidney filtration pressure is not the best explanation for the edema because it is caused by increased blood flow to the kidneys, not malnutrition. Increased blood flow to the kidneys can result from hypertension, diabetes, or renal artery stenosis.
Choice C reason: Decreased capillary osmotic pressure is the best explanation for the edema because it is caused by low plasma protein levels, which are common in malnutrition. Low plasma protein levels reduce the force that pulls fluid back into the capillaries from the interstitial space, leading to fluid accumulation in the tissues.
Choice D reason: Intracellular dehydration is not the best explanation for the edema because it is caused by loss of water from the cells, not malnutrition. Loss of water from the cells can result from hypernatremia, hyperglycemia, or osmotic diuresis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
