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A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in LOC
Correct Answer: D
Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.
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The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?
- A. Notify the healthcare provider of the findings.
- B. Ensure that the IV is infusing at the prescribed rate.
- C. Listen to lung sounds.
- D. Check under his back for evidence of bleeding.
Correct Answer: D
Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.
A young client who is being taught how to use an inhaler for symptoms of asthma tells the nurse about the intention to use the inhaler but plans to continue smoking cigarettes. In evaluating the client's response, what is the best initial action by the nurse?
- A. Explain the risks of smoking with asthma.
- B. Revise the plan of care.
- C. Encourage the client to reduce smoking gradually.
- D. Provide resources for smoking cessation.
Correct Answer: B
Rationale: The best initial action by the nurse is to revise the plan of care. This is necessary to address the client's intention to continue smoking and ensure that appropriate support and education are provided. Choice A is not the best initial action as the client is already aware of the risks of smoking with asthma. Choice C might not be effective as the client's intention to continue smoking poses a significant risk to their health. Choice D, providing resources for smoking cessation, is important but revising the plan of care should come first to address the immediate concern.
The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?
- A. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
- B. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- C. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
- D. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
Correct Answer: B
Rationale: The correct answer is B: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. Tetralogy of Fallot involves these four congenital defects. Choice A is incorrect because it includes aortic stenosis instead of pulmonary stenosis, atrial septal defect instead of ventricular septal defect, and left ventricular hypertrophy instead of right ventricular hypertrophy. Choice C is incorrect as it includes aortic stenosis and atrial septal defect instead of pulmonary stenosis and ventricular septal defect. Choice D is incorrect because it includes aortic hypertrophy instead of overriding aorta.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Has everyone at home already had varicella?
- B. Have the antifungal creams been effective?
- C. Do your family members share combs and brushes?
- D. Do you have any dry patches on your feet and hands?
Correct Answer: A
Rationale: The correct answer is A: 'Has everyone at home already had varicella?' Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. By knowing if others at home had varicella (chickenpox), the nurse can assess the risk of transmission and provide appropriate guidance. Choice B is incorrect because antifungal creams are not effective for herpes zoster, which is a viral infection. Choice C is irrelevant to herpes zoster as it pertains to sharing personal items that may transmit head lice or certain skin infections. Choice D is also unrelated as it focuses on dry patches, not typical manifestations of herpes zoster which presents as a painful rash.
The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?
- A. Pain rated 7/10 on the pain scale.
- B. Mild swelling at the fracture site.
- C. Small amount of bleeding from the surgical site.
- D. Left extremity capillary refill greater than 5 seconds.
Correct Answer: D
Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.