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 is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.
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A client who had major abdominal surgery is having delayed healing of the wound. Which laboratory test result would most closely correlate with this problem?
- A. Decreased albumin
- B. Decreased creatinine
- C. Increased calcium
- D. Increased sodium
Correct Answer: A
Rationale: Decreased albumin indicates protein deficiency, impairing tissue repair and delaying wound healing. Decreased creatinine (B) reflects renal function, increased calcium (C) affects bones, and increased sodium (D) affects fluid balance, not healing directly.
The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?
- A. SGOT and LDH
- B. SGOT and CK BB
- C. LDH and CK MB
- D. LDH and CK BB
Correct Answer: C
Rationale: CK-MB and LDH are specific to cardiac damage, with CK-MB being highly specific for myocardial infarction due to its presence in heart muscle.
Which client should be assigned to the nursing assistant?
- A. The 18-year-old with a fracture to two cervical vertebrae
- B. The infant with meningitis with a temperature of 101°F
- C. The elderly client with a thyroidectomy four days ago
- D. The client with a thoracotomy two days ago
Correct Answer: C
Rationale: The elderly client four days post-thyroidectomy is stable and suitable for a nursing assistant’s care (e.g., basic hygiene, ambulation). The other clients require skilled nursing due to critical conditions (cervical fracture, meningitis, recent thoracotomy).
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
- A. Aplastic crisis
- B. Vaso-occlusive crisis
- C. Dactylitis crisis
- D. Sequestration crisis
Correct Answer: D
Rationale: Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. Dactylitis crisis, or 'hand-foot syndrome,' causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
Place in sequence from 1-5 the proper order for introducing items to the infant's diet.
- A. Strained meats
- B. Whole milk
- C. Rice cereal
- D. Fruits
- E. Vegetables
Correct Answer: C, D, E, A, B
Rationale: Infant diet sequence: rice cereal (C) at 6 months, then fruits (D) and vegetables (E), strained meats (A) around 7-8 months, and whole milk (B) after 12 months.
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