Question

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Answer 1

Correct Answers:

Oral mucosa

Rationale :

🔥The oral mucosa is the most reliable area to assess for central cyanosis, which reflects inadequate oxygenation of circulating blood.

🔥Unlike peripheral cyanosis—which may be due to cold exposure or poor circulation—central cyanosis involves the core organs and tissues, and is best detected in highly vascular areas with thin epithelium.

🔥The tongue and inner lips allow for clear visualization of systemic hypoxemia.

🔥 Soles, palms, and nail beds may show cyanosis due to peripheral vasoconstriction even when oxygenation is adequate, making them less reliable.

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Answer 2

Correct Answers:

Demyelination of nerves that stimulate the respiratory muscles

Rationale :

✅ Guillain-Barré Syndrome (GBS) is a progressive autoimmune disorder that causes demyelination of peripheral nerves, including those that innervate the diaphragm and intercostal muscles.

✅ This results in respiratory muscle weakness, shallow breathing, and eventual respiratory failure if not managed.

✅ Brainstem degeneration and pleural effusion are not characteristic features of GBS.

✅ The respiratory distress seen in this patient is directly linked to loss of nerve conduction to the respiratory muscles.

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Answer 3

Correct Answers:

Pain and swelling in one leg.

Rationale :

In heparin-induced thrombocytopenia (HIT), the immune system forms antibodies that activate platelets, leading to thrombosis rather than bleeding, despite low platelet counts.
The most dangerous complication is the development of deep vein thrombosis (DVT) or pulmonary embolism (PE). Pain and swelling in one leg indicate a possible thrombus, which can lead to life-threatening embolic events.
Petechiae and gum bleeding reflect thrombocytopenia but are less urgent than thrombosis risk.

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Answer 4

Correct Answers:

The client will need additional testing to determine if he has cancer.

Rationale :

🔹Elevated PSA (prostate-specific antigen) is a nonspecific marker and can be elevated due to prostate cancer, benign prostatic hyperplasia (BPH), prostatitis, or even recent urogenital manipulation.

🔹It does not confirm malignancy, but warrants further evaluation, such as digital rectal exam, prostate MRI, or biopsy.

🔹The nurse should recognize that PSA elevation requires additional investigation, not a cancer diagnosis.

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Answer 5

Correct Answers:

Black tea

Rationale :

Premature atrial contractions (PACs) can be triggered by stimulants, including caffeine, found in high amounts in black tea, coffee, chocolate, and energy drinks.
Black tea, as a source of caffeine, may increase the frequency of ectopic beats and exacerbate atrial irritability.
Whole milk, bacon, and scrambled eggs with cheese contain fat and cholesterol but are not directly related to electrical conduction or atrial excitability.

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Answer 6

Correct Answers:

Anticoagulant therapy

Rationale :

🔹For clients with persistent atrial fibrillation (AF), especially when rhythm control has failed, the primary concern becomes stroke prevention due to thrombus formation in the atria, particularly in the left atrial appendage.

🔹Anticoagulant therapy (e.g., warfarin, apixaban) is indicated to prevent embolic events.

🔹Emergency defibrillation is not appropriate unless the patient is unstable.

🔹 CABG addresses coronary artery disease, and diuretics don’t manage rhythm or clot risk in AF.

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Answer 7

Correct Answers:

People who qualify for Medicare will have no out-of-pocket medical expenses.

Rationale :

🔹This statement is incorrect and reflects a common misconception.

🔹While Medicare provides coverage for eligible individuals, it does not cover all medical costs. 🔹Beneficiaries are responsible for premiums, deductibles, and co-pays, and many purchase supplemental insurance (Medigap).

🔹The other statements are true: people with ESRD qualify under 65, dual eligibility with Medicaid is possible, and Medicare is federally funded.

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Answer 8

Correct Answers:

The client takes propranolol for hypertension.

Rationale :

🔹Propranolol, a non-selective beta-blocker, can exacerbate bronchoconstriction in patients with asthma by blocking beta-2 receptors in the bronchial smooth muscle.

🔹This can trigger wheezing and shortness of breath, especially in patients predisposed to bronchospasm.

🔹Asthmatics should use cardio-selective beta-blockers (e.g., metoprolol) if needed.

🔹The other options—rosuvastatin, acetaminophen, vegetarian diet—do not cause bronchoconstriction.

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Answer 9

Correct Answers:

Prevents vagal stimulation to reduce the risk of dysrhythmias

Rationale :

🔹Docusate sodium (Colace) is a stool softener prescribed post-MI to reduce straining during defecation, which can trigger vagal stimulation.

🔹Vagal responses can slow the heart rate and precipitate bradyarrhythmias, which are especially risky in the hemodynamically fragile post-MI patient.

🔹Using stool softeners helps avoid this complication. The medication does not treat lipids, clots, or sodium overload.

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Answer 10

Correct Answers:

Retropulsion

Rationale :

🔸Retropulsion is a form of postural instability seen in Parkinson’s disease, where the patient involuntarily takes backward steps and has difficulty maintaining balance.

🔸This increases the risk for falls and injury. It reflects impaired motor control related to dopaminergic neuron loss in the basal ganglia.

🔸Impaired handwriting relates to bradykinesia, and muscle soreness is nonspecific.

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QLexNursing

1 : A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

2 : A nurse is assessing a client who has Guillain-Barre Syndrome, and notes that the client's breathing is shallow and the client is short of breath. The nurse understands that the client's respiratory distress is caused by which of the following?

3 : A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?

4 : An older adult client who is having difficulty passing urine is found to have elevated levels of prostate-specific antigen (PSA). The nurse understands that this finding indicates which of the following?

5 : A nurse is caring for a 24-year-old client who has frequent premature atrial contractions seen on the cardiac monitor. The nurse understands that the client requires additional education when the client selects which of the following items for the breakfast tray?

7 : A nurse manager is discussing social services for older adults during a staff meeting in a long- term acute care (LTAC) facility. Which statement about Medicare made by one of the employees requires correction by the nurse manager?

8 : A nurse is obtaining an admission history on a client who has possible asthma with new-onset wheezing and shortness of breath. Which information may be a cause of the client's bronchoconstriction?

9 : A nurse is discussing the use of docusate sodium (Colace) with a client who is recovering from a non-ST elevation myocardial infarction (NSTEMI). What is the rationale for administering this medication during the recovery from a myocardial infarction?

10 : The classic manifestations associated with Parkinson's disease are tremor, rigidity, bradykinesia, and postural instability. The nurse understands that a finding related to postural instability includes which of the following?