Remar exam 2
A nurse is doing an admission assessment on a client who has multiple bruises on her
body. The nurse suspects abuse. Which of the following statements is the most
appropriate for the nurse to ask?
Are you being hurt by your partner?
Are you happy with your home environment?
Do you and your partner have problems resolving personal conflict
Do you feel afraid when your partner is around ? - CORRECT ANSWER-d" Great job!
Abuse is defined as the intentional infliction of injury, mental or physical or intentional
neglect of care. A direct question is needed to assess if this is happening.
A nurse is caring for a client who has suspected internal bleeding. A nurse is aware the
signs of clotting and bleeding concurrently indicate:
Hemophilia
Polycythemia Vera
Dismesnated Itnravular cogultion - CORRECT ANSWER-Great job! Disseminated
intravascular coagulation (DIC) is a rare, life-threatening condition that prevents blood
from clotting normally. The blood clots reduce blood flow and can block blood from
reaching bodily organs. This increased clotting can use up the blood's platelets and
clotting factors. Fewer platelets and clotting factors available result in excessive
bleeding. Hemophilia A, also called factor VIII (FVIII) is a genetic disorder caused by
missing or defective factor VIII, a clotting protein so blood does not clot properly.
Polycythemia vera is a disorder of the bone marrow. It mainly causes too many red
blood cells to be produced.
A nurse is caring for a client with peripheral vascular disease and notices the legs are
cold and blue. Which is the priority action for the nurse to take?
Notify the doctor
Assess for distal pulses
Adminster epinephrine
chart the obstervation - CORRECT ANSWER-a.
That is incorrect. Peripheral vascular disease typically strikes the veins and arteries that
supply the arms, legs, and a client's leg looks pale or blue; the leg becomes cold; a
nurse should check the pulses before notifying the physician. The presence of a pulse
will need to be given to the physician.
