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A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?
- A. Avoid foods high in iodine.
- B. Take your medication with meals.
- C. Monitor your weight daily.
- D. Decrease your daily fluid intake.
Correct Answer: A
Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.
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At a motor vehicle collision site, a nurse applies pressure to a groin wound that is bleeding profusely until emergency personnel arrive. Subsequently, the client undergoes leg amputation and sues the nurse for malpractice. What is the most likely outcome of this lawsuit?
- A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
- B. The lawsuit may be settled out of court, but the nurse's license is unlikely to be revoked.
- C. There will be no judgment against the nurse, as their actions were protected under the Good Samaritan Act.
- D. The client will win because the four elements of negligence (duty, breach, causation, and damages) cannot be proved.
Correct Answer: C
Rationale: The Good Samaritan Act shields healthcare professionals who act in good faith and offer reasonable care from malpractice claims, irrespective of the client's outcome. In this scenario, the nurse stopping to render aid at the accident scene and applying pressure to the bleeding groin wound would likely be covered by the Good Samaritan Act, protecting the nurse from legal repercussions related to the subsequent leg amputation.
The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:
- A. Work on establishing rapport with the patient.
- B. Use humor to lighten emotionally charged topics of discussion.
- C. Empathize with the patient when the patient shares sad feelings.
- D. Demonstrate respect when discussing emotionally charged topics.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?
- A. Performing ROM exercises during bathing.
- B. Changing the patient's position every two hours.
- C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
- D. Placing the patient in the prone position for one hour three times a day.
Correct Answer: C
Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
- A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
- B. Instruct the UAP not to wake the client under any circumstances during the night.
- C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
- D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.
Correct Answer: A
Rationale: The best action for the nurse is to determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. By incorporating familiar bedtime rituals that do not compromise the client's safety, the nurse can help the client fall asleep faster and improve the overall quality of care provided to the client.
What action should be taken when adding sterile liquids to a sterile field?
- A. Use an expired sterile liquid if the bottle is sealed and unopened.
- B. Consider the sterile field contaminated if it becomes wet during the procedure.
- C. Remove the container cap and place it with the inside facing up on the sterile field.
- D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.
Correct Answer: B
Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.