HESI Case Study - Pernicious Anemia exam with 100% correct answers

Introduction The client is a 45-year-old male who was admitted to the medical-surgical unit 6 hours ago from the Emergency Department (ED) due to nausea, vomiting, shortness of breath, pallor, weakness, and severe fatigue. He also has had a medical history of chronic gastric ulcers. The nurse receives shift report and proceeds to the client's room, bringing equipment to measure his vital signs. Which vital sign should concern the nurse the most? A. Blood pressure is 142/80 mmHg. B. Respiration rate of 24 breaths/minute. C. Heart rate of 98 beats/minute. D. Pulse oxygenation of 94%. A This elevated blood pressure could indicate an underlying issue that should be addressed. The nurse asks the client how he is feeling. He reports that he does not have time for this hospitalization. The nurse notes that he seems annoyed. He coughs as he tries to sit up. He turns on the television, focuses on a news station, and ignores the nurse. Which type of assessment should the nurse perform on the client? A. A focused assessment. B. A comprehensive assessment. C. An emergency assessment. D. A psychosocial assessment. A This assessment is for evaluating the status of specific previously identified problems and any symptoms of new problems developing. The nurse performs a focused assessment. Which systems should the nurse evaluate? (Select all that apply. One, some, or all options may be correct.) Select all that apply. A. Neurological system. B. Cardiovascular system. C. Respiratory system. D. Integumentary system. E. Gastrointestinal system. B, C, E The client has hypertension and an elevated heart rate. The client has a cough. The client has a history of having gastric ulcers and he currently has nausea and vomiting symptoms. The nurse finds that the client has a weak, irregular, and rapid pulse and his tongue is inflamed. The nurse decides to perform a neurological assessment because of mild tremoring. His unexpected neurological findings include hyperactive deep tendon reflexes and mild burning and prickling sensations on his feet and hands. He also appears to startle easily, and he has lost about 15% of his weight compared to his last visit, which was four months ago. During the assessment, the nurse suspects that the client may have pernicious anemia. Which pathophysiological process promotes this condition? A. Presence of Reed-Sternberg cells. B. Diminished total iron-binding capacity. C. Destruction of gastric parietal cells. D. Inadequate intake of dietary folate. C Pernicious anemia is often associated with chronic gastritis. This is because destruction of gastric parietal cells due to inflammation and cellular hypoxia causes gradual gastric atrophy and a reduction of available intrinsic factor, which is a transporter molecule that is required to promote the bioavailability of vitamin B12. The nurse finishes documenting the client interview and notices that new laboratory results have been posted in the electronic medical record (EMR). The nurse notes that the serum magnesium level is 1.22 mg/dL (0.50 mmol/L), and the normal range is 1.58 to 2.55 mg/dL (0.65 to 1.05 mmol/L). Which other result will need intervention? A. Chloride of 99 mEq/L (99 mmol/L). B. Potassium of 2.9 mEq/L (2.9 mmol/L). C. Glucose of 105 mg/dL (5.83 mmol/L). D. Sodium of 137 mEq/L (137 mmol/L). B This is a low serum potassium level; normal range is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Which action is most important for the nurse to perform before calling the healthcare provider (HCP) to report the lab values? A. Initiate telemetry. B. Complete an SBAR form. C. Give PO potassium chloride. D. Notify the unit manager. A Although telemetry does require a healthcare provider's order, most hospitals have a standing order/protocol in place for situations such as this one. Telemetry placement is essential to protect the client from potential decompensation due to cardiac dysrhythmias which could occur due to hypokalemia. Which sign or diagnostic result should the nurse expect to observe in a client due to hypokalemia? A. An arm tremor while taking the client's blood pressure. B. Hyperactive deep tendon reflexes. C. Elevated serum glucose level. D. A dampened or flattened T-wave on an electrocardiogram (ECG). D A dampened or flattened T-wave on an electrocardiogram (ECG) is an expected finding due to hypokalemia. This is also the reason that the client should be placed on telemetry until the hypokalemia is resolved. Morning laboratory results have begun appearing in the client's electronic medical record (EMR). Which electrolyte deficiency would make the nurse suspect that this client may be suffering from chronic alcohol use? A. Potassium. B. Magnesium. C. Phosphate. D. Sodium. B A magnesium deficit is consistent with the client's assessment findings, and it is commonly associated with chronic alcohol use. The nurse assesses the client's lifestyle choices to explore what resources he has for health promotion. Which lifestyle choice could concern the nurse about a client with possible chronic alcohol use? A. Sexual preferences. B. He works ten to twelve hours every day in the office. C. He prefers to live in a city where there is a lot of action. D. He enjoys staying out all night at his favorite local bar. D While the bar may provide social stimulation, it also provides access to alcohol. The client is 45-years-old. Which life style choice is surprising given his psychosocial developmental stage based on Erikson? A. His sexual preferences. B. He prefers to live in a city where there is a lot of action. C. He enjoys staying out all night at his favorite local bar. D. He works ten to twelve hours every day in the office. C Regularly staying out all night is the behavior of someone younger who is seeking intimacy which, according to Erikson, is a psychosocial developmental stage for early adulthood. Middle adulthood is staged as a time of generativity versus stagnation. The nurse notes that the client has had many personal losses in his life, and he recently lost his legal partner in an accident. His electronic medical record (EMR) has no one listed as a person to contact in case of emergencies. Which question is the best way for the nurse to begin assessing the client's support systems and available resources? A. "Can you tell me more about what happened to your professional partner?" B. "Which neighborhood bar do you regularly go to after work in the evenings?" C. "I'm sorry for your loss. Was your legal partner also your domestic partner?" D. "Who would you like to have listed as your emergency contact person?" D Initiating the conversation using a focused question for information about electronic record data omissions is a less threatening way to begin to ask the question, "To whom can you go to for support at home or at work?" The nurse has received new orders by electronic medical record (EMR) in response to the recent laboratory results. One of the orders is for intravenous potassium chloride 20 mEq/100 mL over one hour. Which drug implications are important for the nurse to consider before giving it? (Select all that apply. One, some, or all options may be correct.) A. The intravenous site should be monitored closely for infiltration. B. Giving the infusion too rapidly can cause fatal hyperkalemia. C. It should be injected directly and slowly by intravenous push. D. The intravenous infusion is best given through a central line. E. The intravenous potassium can be given by gravity infusion. F. Administering the intravenous medication can burn a peripheral vein. A, B, D, F This is a very important nursing action as infiltration can lead to painful and damaging extravasation around the intravenous catheter site. This is a true statement. This is the preferred intravenous route; however, a slower flow rate can be used if this is not possible. This is an important nursing consideration and can be rectified by slowing the rate and/or reducing the potassium concentration in the intravenous medication bag. The nurse notices that the client has no central line and only has one peripheral intravenous catheter in the left forearm. Which intervention is the best way to give the ordered potassium? A. Consult with a pharmacist about giving it slowly over two hours. B. Administer the intravenous potassium as it was ordered. C. Call the healthcare provider and request a new order. D. Inject lidocaine into the intravenous bag and give as prescribed. A This option is the easiest way to prevent vein irritation while administering the ordered medication. Pharmacists are the best colleagues to consult for situations like this one. Most of the time, the pharmacist can adjust the medication; however, if this is not the case, the pharmacist can also assist with communicating with the healthcare provider (HCP). Mr. Baker starts vomiting. The nurse looks in his medication administration record and notices that he has a prescription for treating nausea and vomiting. He has also not had any of it since he was admitted to the unit. The healthcare provider has prescribed ondansetron (Zofran) 8 mg iv push every 8 hours as needed. How many milliliters (mL) of ondansetron (Zofran) should the nurse should draw into a syringe in preparation for administration? (enter numerical value only. If rounding is necessary, round to the whole number.) 10