Nokea
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers of clothing is a safe and effective way to manage cold intolerance in hypothyroidism, avoiding risks associated with electric blankets or heating pads.
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The physician has ordered Basalgel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include:
- A. Constipation
- B. Urinary retention
- C. Diarrhea
- D. Confusion
Correct Answer: A
Rationale: Aluminum-based antacids like Basalgel commonly cause constipation due to their effect on intestinal motility.
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
Which of the following are common neurological changes associated with aging? Select all that apply.
- A. Dementia occurs.
- B. Threshold for sensory input increases.
- C. Perspiration is reduced.
- D. Short-term memory is impaired.
- E. Muscles atrophy.
Correct Answer: B,D
Rationale: Aging commonly increases sensory input threshold (B), making stimuli harder to perceive, and impairs short-term memory (D). Dementia (A) is not universal, perspiration reduction (C) is not neurological, and muscle atrophy (E) is musculoskeletal.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
- A. Altered nutrition
- B. Impaired communication
- C. Risk for injury/aspiration
- D. Altered urinary elimination
Correct Answer: C
Rationale: Post-tonsillectomy, the risk of bleeding and aspiration is a priority due to the surgical site in the throat.