Nokea
A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
- A. Weight gain
- B. Weight loss
- C. Tachycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.
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Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?
- A. Assessing and maintaining a patent airway
- B. Obtaining vital signs
- C. Using the Glasgow Coma Scale to check responsiveness
- D. Controlling bleeding
Correct Answer: B
Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.
An obstructing stone in the renal pelvis or upper ureter causes:
- A. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males
- B. Urinary frequency and dysuria
- C. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor
- D. Dull, aching, back pain
Correct Answer: C
Rationale: Radiating pain in the urethra in both sexes, extending into the labia in females and into the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter. Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter within the bladder wall. An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor. Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the renal pelvis or upper ureter causes severe flank and abdominal pain.
Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
- A. She should be able to control evacuation of her bowels.
- B. She should be able to return to a regular diet.
- C. She should be able to resume sexual activity.
- D. She should be able to manage her own care.
Correct Answer: A
Rationale: Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. The client should be able to resume sexual activity. She will be able to wear a pouch. The client has no other health or mental problems and should be able to manage her own ileostomy.
A client with a history of trigeminal neuralgia is admitted with complaints of facial pain. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: A
Rationale: Trigeminal neuralgia causes severe facial pain, so administering analgesics is the priority to relieve discomfort.
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.