The nurse provides care for a client with a hemoglobin of 8 g/dL (80 g/L) due to acute blood loss. Which finding does the nurse expect to assess?

Shallow respirations and a smooth, beefy red tongue

Facial flushing with distended neck veins

Bilateral numbness and tingling of the extremities

Increased heart rate and decreased mental alertness

Answer and Explanation

The Correct Answer is D

Choice A reason: Shallow respirations and a smooth, beefy red tongue are not the expected findings because they are signs of pernicious anemia, not acute blood loss. Pernicious anemia is a condition where the body cannot produce enough red blood cells due to a lack of vitamin B12, which is needed for DNA synthesis and cell division. Pernicious anemia can cause shallow respirations due to hypoxia, which is a low level of oxygen in the tissues, and a smooth, beefy red tongue due to atrophy of the tongue papillae, which are the small projections that give the tongue its rough texture.

Choice B reason: Facial flushing with distended neck veins are not the expected findings because they are signs of polycythemia, not acute blood loss. Polycythemia is a condition where the body produces too many red blood cells, which increases the blood volume and the blood viscosity, making the blood thicker and harder to flow. Polycythemia can cause facial flushing due to increased blood flow to the skin, and distended neck veins due to increased pressure in the venous system.

Choice C reason: Bilateral numbness and tingling of the extremities are not the expected findings because they are signs of peripheral neuropathy, not acute blood loss. Peripheral neuropathy is a condition where the nerves that carry signals from the brain and spinal cord to the rest of the body are damaged or impaired, causing sensory and motor disturbances. Peripheral neuropathy can cause bilateral numbness and tingling of the extremities due to reduced nerve conduction and sensation.

Choice D reason: Increased heart rate and decreased mental alertness are the expected findings because they are signs of acute blood loss. Acute blood loss is a condition where the body loses a large amount of blood in a short period of time, which reduces the oxygen-carrying capacity of the blood and the tissue perfusion. Acute blood loss can cause increased heart rate due to the compensatory mechanism of the body to increase the cardiac output and maintain the blood pressure, and decreased mental alertness due to the reduced oxygen delivery to the brain.

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Correct Answer is D

Explanation

Choice A reason: The thyroid gland is cancerous is not a correct description of a goiter. A goiter is a non-specific term that refers to any enlargement of the thyroid gland, which may have various causes and may or may not be associated with thyroid cancer.

Choice B reason: The client has a low serum calcium level is not a correct description of a goiter. A low serum calcium level is a sign of hypoparathyroidism, which is a condition that affects the parathyroid glands, not the thyroid gland. The parathyroid glands are located behind the thyroid gland and regulate the calcium and phosphorus levels in the blood.

Choice C reason: The thyroid gland has been surgically removed is not a correct description of a goiter. A goiter is a condition that involves the presence of an enlarged thyroid gland, not the absence of it. A surgical removal of the thyroid gland is called a thyroidectomy, which may be done for various reasons such as thyroid cancer, hyperthyroidism, or large goiters.

Choice D reason: The thyroid gland is enlarged is the best description of a goiter. A goiter is a condition that involves the enlargement of the thyroid gland, which may be due to iodine deficiency, autoimmune disease, inflammation, infection, benign nodules, or thyroid hormone imbalance. A goiter may cause symptoms such as difficulty swallowing, breathing, or speaking, hoarseness, cough, or neck discomfort.

A. Increased serum hydrostatic pressure B. Increased kidney filtration pressure C. Decreased capillary osmotic pressure D. Intracellular dehydration

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.

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The nurse provides care for a client with a hemoglobin of 8 g/dL (80 g/L) due to acute blood loss. Which finding does the nurse expect to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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