The nurse is caring for a patient with severe anemia and a hemoglobin level of 4 g/dL. Which clinical manifestation will the nurse expect the patient to exhibit?

Petechiae

Glossitis

Exertional dyspnea

Palpitations

Answer and Explanation

The Correct Answer is C

Choice A reason: Petechiae are small red or purple spots caused by bleeding into the skin, typically not directly associated with anemia.

Choice B reason: Glossitis, which is inflammation of the tongue, can be associated with certain types of anemia but is not specifically related to the low hemoglobin level itself.

Choice C reason: Exertional dyspnea, or difficulty breathing upon exertion, is a common symptom of severe anemia due to the reduced oxygen-carrying capacity of the blood.

Choice D reason: Palpitations, or feeling that the heart is racing or fluttering, can occur in severe anemia as the heart attempts to compensate for the lack of oxygen in the blood.

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Correct Answer is B

Explanation

Choice A reason: Providing a pillow to brace the incision is a recommended practice to support the incision during coughing or movement.

Choice B reason: Instructing the patient to perform deep coughing every 30 minutes is a standard postoperative care practice to prevent atelectasis.

Choice C reason: Having the patient sit up and lean forward can help with breathing and comfort after surgery.

Choice D reason: Giving pain medication prior to coughing is actually a recommended practice to reduce pain and facilitate effective coughing.

A. Observe the patient's nonverbal communication for data on the patient's thoughts and feelings. B. Maximize stimuli to create diversion from the anxiety. C. Discourage activities, as activities might only increase a patient's anxiety level. D. Document only positive changes in behavior. E. Encourage the patient to verbalize all thoughts and feelings. F. Observe for signs of suicidal thoughts.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.

Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.

Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.

Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.

Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.

Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.

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The nurse is caring for a patient with severe anemia and a hemoglobin level of 4 g/dL. Which clinical manifestation will the nurse expect the patient to exhibit?

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