Nokea
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- A. Impaired physical mobility related to decreased endurance
- B. Hypothermia r/t decreased metabolic rate
- C. Disturbed thought processes r/t interstitial edema
- D. Decreased cardiac output r/t bradycardia
Correct Answer: D
Rationale: Bradycardia in hypothyroidism can lead to decreased cardiac output, which is life-threatening and thus the highest priority diagnosis.
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The nurse is taking care of an elderly client with congestive heart failure. Which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.
- A. obtain daily weight
- B. provide assistance with self-care activities
- C. provide sensory stimulation
- D. check vital signs after activity
Correct Answer: A, B, D
Rationale: Daily weights monitor fluid status, assistance with self-care reduces exertion, and post-activity vital signs assess heart workload. Sensory stimulation may increase stress.
The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply.
- A. normal childhood
- B. family history of depression
- C. recent major life change
- D. Lipitor used to treat high blood pressure
Correct Answer: B, C
Rationale: Family history of depression and recent major life changes are known risk factors for clinical depression. A normal childhood is not a risk factor, and Lipitor treats cholesterol, not blood pressure.
The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?
- A. The client eats all the food on her tray
- B. The client requests that family bring special foods
- C. The client's weight has increased
- D. The client weighs herself each morning
Correct Answer: C
Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.
A nursing instructor demonstrates to several students how to wrap an amputated limb in a bandage using a figure eight technique. Which of the following correctly states the benefits of this technique? Select all that apply.
- A. prevents blood clots from forming
- B. reduces post-operative swelling
- C. minimizes pain and discomfort
- D. prevents exposure to air
Correct Answer: B,C
Rationale: The figure-eight technique reduces swelling (B) by promoting venous return and minimizes pain (C) by stabilizing the limb. It does not prevent clots (A) or air exposure (D).
A nurse is triaging in the emergency room when a client enters complaining of muscle cramps and a feeling of exhaustion after a running competition. Which of the following would the nurse suspect?
- A. Hypernatremia
- B. Hyponatremia
- C. Syndrome of inappropriate antidiuretic hormone (SIADH)
- D. Decreased potassium
Correct Answer: B
Rationale: Hyponatremia is common in runners due to excessive water intake or sodium loss through sweat, leading to muscle cramps and exhaustion. Hypernatremia, SIADH, or low potassium would present differently.