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A client has a new diagnosis of hypothyroidism. Which of the following interventions should the nurse include in the plan of care?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Increase iodine intake.
Correct Answer: B
Rationale: The correct intervention for a client with hypothyroidism is to encourage frequent rest periods. Hypothyroidism often leads to fatigue, making rest essential for recovery and symptom management. Providing a high-calorie diet is not necessary unless the client has gained weight due to hypothyroidism. Restricting fluid intake is not indicated unless there are specific medical reasons for it. Increasing iodine intake is not recommended for primary hypothyroidism, as it is typically caused by autoimmune thyroiditis or other factors rather than iodine deficiency.
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During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned infants.
- B. Port wine stains are typically associated with other malformations.
- C. Telangiectatic nevi are normal and will disappear as the baby grows.
- D. The child is too young for surgical removal of these at this time.
Correct Answer: C
Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.
A client is being taught about dietary management of hypercholesterolemia. Which of the following foods should be suggested to add to the diet?
- A. Avocados
- B. Fried chicken
- C. Whole milk
- D. Bacon
Correct Answer: A
Rationale: Avocados are a good choice to suggest adding to the diet of a client with hypercholesterolemia because they are high in healthy fats, particularly monounsaturated fats, which can help manage cholesterol levels. On the other hand, fried chicken, whole milk, and bacon are high in saturated fats and cholesterol, which should be limited in a diet aimed at managing hypercholesterolemia. Therefore, choices B, C, and D are incorrect.
While measuring a client's oral temperature using an electronic thermometer, what action should the nurse take?
- A. Assist the client with oral hygiene before taking the temperature.
- B. Inquire whether the client has smoked in the last 30 minutes.
- C. Connect the red tip probe to the thermometer unit.
- D. Position the probe tip against the client's buccal mucosa.
Correct Answer: B
Rationale: The correct action for the nurse to take when measuring a client's oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.
A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?
- A. Encourage the client to relax and take deep breaths during the dressing change.
- B. Educate the client about the importance of pain management postoperatively.
- C. Assist the client to a comfortable position for the dressing change.
- D. Administer pain medication 45 minutes before changing the client's dressing.
Correct Answer: D
Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.
A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?
- A. Heart rate of 52 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Blood glucose level of 180 mg/dL
- D. Potassium level of 4.0 mEq/L
Correct Answer: A
Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.