Nokea
A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?
- A. Risk for injury related to exophthalmos
- B. Impaired social interaction related to emotional lability
- C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
- D. Activity intolerance related to fatigue
Correct Answer: D
Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.
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A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 episodes of incontinent diarrhea
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: A malnourished client on bed rest is at the highest risk for developing decubitus ulcers due to a combination of factors such as poor nutritional status and immobility. Malnourished individuals have compromised skin integrity, making them more susceptible to pressure ulcers. Being on bed rest further exacerbates this risk as constant pressure on bony prominences can lead to tissue damage. Although the other choices may also be at risk for developing decubitus ulcers, the malnourished client on bed rest presents the highest risk due to the combination of malnutrition and immobility.
A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.
- B. I have been coughing up foul-tasting, brown, thick sputum.
- C. I have been sweating all day.
- D. I feel hot off and on.
Correct Answer: B
Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.
A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?
- A. A heart rate of 90 beats per minute
- B. A blood pressure of 120/80 mm Hg
- C. A respiratory rate of 16 breaths per minute
- D. A temperature of 98.6 degrees Fahrenheit
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.
A nurse is reinforcing teaching about foods that enhance iron absorption when consumed with nonheme iron with a client who has iron deficiency anemia. Which of the following foods should the nurse include in the teaching?
- A. Tomato juice
- B. Tea
- C. Milk
- D. Dried beans
Correct Answer: A
Rationale: The correct answer is A, Tomato juice. Tomato juice is high in vitamin C, which enhances the absorption of nonheme iron from foods. Vitamin C helps convert nonheme iron to a form that is easier for the body to absorb. Tea (choice B) contains tannins that can inhibit iron absorption. Milk (choice C) contains calcium, which can interfere with iron absorption. Dried beans (choice D) are a good source of nonheme iron but do not enhance iron absorption when consumed with nonheme iron.
Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive stool culture for Shigella
- B. An elderly factory worker with a positive lab report for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination for Pneumocystis carinii from an induced sputum
- D. A middle-aged nurse with a history of varicella-zoster virus and crops of vesicles on an erythematous base appearing on the skin
Correct Answer: B
Rationale: The correct answer is B because a positive acid-fast bacillus smear in an elderly factory worker suggests tuberculosis, a serious communicable disease that must be reported promptly to the public health department to prevent its spread. Choice A is incorrect as Shigella is an important pathogen, but it does not require immediate public health reporting. Choice C is incorrect because Pneumocystis carinii is an opportunistic pathogen and does not require urgent public health reporting. Choice D is incorrect as varicella-zoster virus causes chickenpox and shingles, both of which are not reportable diseases to the public health department.