Nokea
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
You may also like to solve these questions
The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which assessment findings does the nurse expect to find documented in the client's medical record? Select all that apply.
- A. Edema
- B. Anemia
- C. Polyuria
- D. Bradycardia
- E. Hypotension
- F. Osteoporosis
Correct Answer: A,B
Rationale: The manifestations of ESRD are the result of impaired kidney function. Two functions of the kidney are maintenance of water balance in the body and the secretion of erythropoietin, which stimulates red blood cell formation in bone marrow. Impairment of these functions results in edema and anemia. Kidney failure results in decreased urine production and increased blood pressure. Tachycardia is a result of increased fluid load on the heart. Osteoporosis is not a common finding with ESRD.
Which observation by the nurse indicates a need to suction a client with an endotracheal (ET) tube attached to a mechanical ventilator? Select all that apply.
- A. Audible crackles
- B. Client notably restless
- C. Visible mucus bubbling in the ET tube
- D. Apical pulse rate of 72 beats per minute
- E. Low peak inspiratory pressure on the ventilator
- F. High alarm pressures identified by the ventilator
Correct Answer: A,B,C,F
Rationale: Indications for suctioning include visible mucus bubbling in the ET tube, wet respirations, restlessness, rhonchi or crackles on auscultation of the lungs, increased pulse and respiratory rates, and increased peak inspiratory pressures on the ventilator and high-pressure alarms on the ventilator. A low peak inspiratory pressure indicates a leak in the mechanical ventilation system.
The nurse is performing an assessment on a female client who is suspected of having mittelschmerz. Which subjective finding supports the possibility of this condition?
- A. Experiences pain during intercourse
- B. Has pain at the onset of menstruation
- C. Experiences profuse vaginal bleeding
- D. Has sharp pelvic pain during ovulation
Correct Answer: D
Rationale: Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by a growth follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts 1 to 3 days, and slight vaginal bleeding may accompany the discomfort.
The nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. Which intervention will the nurse implement immediately before reinserting the inner cannula?
- A. Rinsing it in sterile water
- B. Suctioning the client's airway
- C. Tapping it gently against a sterile basin
- D. Drying it with the provided pipe cleaners
Correct Answer: D
Rationale: After washing and rinsing the inner cannula, the nurse taps it dry to remove large water droplets and then uses pipe cleaners specifically for use with a tracheostomy to dry it; then the nurse inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. The nurse should avoid shaking or tapping the inner cannula to prevent contamination. A wet cannula should not be inserted into a tracheostomy because water is a lung irritant.
The nurse prepares the client for the removal of a nasogastric tube. During the tube removal, the nurse instructs the client to take which action?
- A. Inhale deeply.
- B. Exhale slowly.
- C. Hold in a deep breath.
- D. Pause between breaths.
Correct Answer: C
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal. The maneuver partially occludes the airway during tube removal; afterward, the client exhales as soon as the tube is out and thus avoids drawing the gastric contents into the trachea.