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A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?
- A. Improved tolerance to cold.
- B. Decreased fatigue and improved energy levels.
- C. Reduced anxiety and improved mood.
- D. Increased sensitivity to heat.
Correct Answer: B
Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.
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Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Witness the consent and sign the form as a witness
- B. Inform the client of alternatives to the procedure
- C. Explain the procedure in detail to the client
- D. Determine that the surgical consent form has been signed and is included in the client's record
Correct Answer: D
Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.
A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?
- A. Encourage the client to ignore the voices and stay focused on reality.
- B. Acknowledge the client's feelings and ask what the voices are saying.
- C. Redirect the conversation to help distract the client from the hallucinations.
- D. Offer reassurance that the voices cannot harm the client.
Correct Answer: B
Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.
A woman who is breastfeeding calls her obstetrician's office and reports increased anxiety since the vaginal delivery of her son three weeks ago. She stopped taking her antianxiety medications but is thinking of restarting them. What response should the nurse provide?
- A. Describe the potential transmission of drugs to the infant through breast milk.
- B. Encourage her to utilize stress-relieving alternatives, such as deep breathing.
- C. Explain that anxiety is a common reaction for mothers of 3-week-old infants.
- D. Inform her that some antianxiety medications are safe to take while breastfeeding.
Correct Answer: D
Rationale: The correct answer is D because some antianxiety medications are considered safe during breastfeeding. The nurse should reassure the client and encourage her to discuss options with her healthcare provider to manage anxiety safely while continuing to breastfeed. Choice A is incorrect because it focuses on the transmission of drugs rather than providing guidance on safe medication use. Choice B, while promoting stress-relieving techniques, does not address the potential need for medication. Choice C is incorrect as it minimizes the woman's reported anxiety, which may require professional intervention.
A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?
- A. Productive cough with yellow sputum.
- B. Oxygen saturation of 88%.
- C. Respiratory rate of 20 breaths per minute.
- D. Heart rate of 90 beats per minute.
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.
A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
- A. Inform the healthcare provider
- B. Determine the client's need for pain medication
- C. Begin comfort measures
- D. Ensure all life-saving equipment is removed
Correct Answer: B
Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.