What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

diarrhea

diaphoresis

fainting

vomiting

Answer and Explanation

The Correct Answer is C

(a) Diarrhea: Diarrhea is an abnormal gastrointestinal response characterized by frequent, loose, or watery stools. It can be caused by infections, medications, or underlying gastrointestinal disorders. Pallor, or paleness of the skin, typically does not directly lead to diarrhea unless there are specific underlying conditions affecting both circulation and gastrointestinal function.

(b) Diaphoresis: Diaphoresis refers to excessive sweating, which can occur due to sympathetic nervous system activation, fever, or anxiety. While diaphoresis may be associated with conditions causing increased sympathetic activity, it is not directly related to pallor, which indicates reduced blood flow to the skin.

(c) Fainting: Pallor is often a sign of decreased blood flow to the skin, indicating potential hypoperfusion. If severe, this reduced circulation can lead to fainting (syncope) due to inadequate blood supply to the brain. Therefore, after noting pallor, the nurse should be prepared to manage the client for potential fainting episodes by ensuring safety and providing appropriate interventions.

(d) Vomiting: Vomiting is the forceful expulsion of stomach contents through the mouth and can be caused by various factors such as gastrointestinal irritation, infection, or systemic illnesses. Pallor does not directly cause vomiting, although severe systemic conditions affecting circulation could potentially lead to nausea and vomiting as part of a broader clinical picture.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. To prevent further dehydration:

While preventing dehydration is important, it is not the primary reason for bringing a cup of water when assessing the thyroid gland. Dehydration is addressed through overall fluid management rather than during a specific thyroid exam.

B. To assist the client to feel more comfortable:

Providing comfort is essential, but bringing a cup of water specifically for comfort during a thyroid exam is not typically necessary. The primary focus of the water in this context is related to the assessment process.

C. To observe the movement of the thyroid gland:

Observing the movement of the thyroid gland during swallowing can help the nurse assess for abnormalities. Having the client drink water allows the nurse to observe the thyroid gland's movement, which can indicate the presence of goiters, nodules, or other irregularities.

D. To promote the nurse-client relationship:

Promoting a good nurse-client relationship is always beneficial, but bringing a cup of water for this specific purpose is not relevant to the physical assessment of the thyroid gland. The water's main purpose is to facilitate the physical examination process.

A. Accessibility B. Food preparation C. Food preferences D. Finances

Correct Answer is A

Explanation

A) Accessibility:

Accessibility refers to the client's ability to obtain food, which is crucial for nutritional status, especially for someone who lives alone and cannot drive. Difficulty in accessing grocery stores or markets can limit the variety and availability of nutritious food options, potentially leading to poor nutritional intake.

B) Food preparation:

Food preparation skills are important, but if the client has difficulty accessing food in the first place (due to transportation limitations), their ability to prepare meals becomes secondary. Accessibility to food sources is a more immediate concern for nutritional status.

C) Food preferences:

While food preferences can influence dietary choices, the ability to access food is a more fundamental issue that directly impacts nutritional intake, especially for someone who lives alone and has limited mobility.

D) Finances:

Financial constraints can certainly affect food choices and access to nutritious options. However, in this scenario, the primary concern is the physical accessibility to food sources, which directly impacts the client's ability to maintain adequate nutrition.

View Question and Answer

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

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

Correct Answer is C

Explanation

A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?

Correct Answer is A

Explanation

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

Which of the following would a nurse expect to assess in a client with esotropia?

A patient is diagnosed with Homonymous Hemianopsia. The nurse expects to find what defects in the visual field of this patient:

A nurse assesses a 60kg adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client? Round to the whole number.

The nurse is doing a focus assessment on a 25-year-old college student who presented to the clinic secondary to fever and lethargy. When recording the findings of the lymph glands, a nurse should note all except:

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

A nurse is instructing a group of clients regarding nutrition. Which of the following is a good source of omega-3 fatty acids that the nurse should include in the teaching?