HESI Case Study - Pernicious Anemia| Questions and Answers with complete

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