Nokea
A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. Bradycardia
- B. Decreased appetite
- C. Exophthalmos
- D. Weight gain
Correct Answer: C
Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.
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A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
- A. Providing a calm environment
- B. Obtaining a diet history
- C. Administering an analgesic
- D. Assessing fetal heart tones
Correct Answer: D
Rationale: Severe hypertension (180/96) poses a risk to fetal well-being, prioritizing fetal heart tone assessment.
A woman is receiving outpatient treatment at a mental health center. She starts crying and tells the nurse her husband has filed for divorce. The best response from the nurse is
- A. I am so sorry. I am divorced too, but it worked out for the best.'
- B. About half of marriages end in divorce these days.'
- C. You have to let him go and move on with your life.'
- D. Tell me what happened.'
Correct Answer: D
Rationale: An open-ended response like 'Tell me what happened' encourages the client to express feelings, fostering therapeutic communication.
A client recently diagnosed with atrial fibrillation is being discharged home on digoxin (Lanoxin). The nurse is providing education to the client and family. Which client statement indicates the need for further teaching?
- A. I should take my medicine at the same time each day.
- B. If I miss a dose, I can take it as soon as I remember it.
- C. I need to call my doctor if my heart rate goes below 60 or above 110.
- D. Changes in my vision could be toxicity and should be reported immediately.
Correct Answer: B
Rationale: Taking a missed digoxin dose as soon as remembered is incorrect; clients should skip it if it’s close to the next dose to avoid toxicity. Other statements reflect correct understanding.
A Turkish-speaking client is scheduled for a colonoscopy, and the nurse must provide printed directions to the client, but directions are not available in Turkish. Which of the following is most appropriate?
- A. The nurse contacts a medical translator to translate.
- B. The client's 10-year-old daughter translates the directions.
- C. The nurse draws pictures and pantomimes directions.
- D. Client's daughter is advised to tell her parent to seek a translator.
Correct Answer: A
Rationale: Contacting a medical translator (A) ensures accurate communication for critical medical instructions. Using a child (B) is unreliable, pictures/pantomime (C) may be unclear, and advising the daughter to find a translator (D) shifts responsibility inappropriately.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
- A. The child is placed in a private room.
- B. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- D. The staff uses standard precautions.
Correct Answer: A
Rationale: contact precautions required for diapered or incontinent clients