Nokea
A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement?
- A. Review most recent thyroid function test results
- B. Encourage the client to take an afternoon nap.
- C. Refer the client for a psychiatric evaluation.
- D. Suggest reducing fluid intake before bedtime.
Correct Answer: A
Rationale: Hypothyroidism can cause depression and sleep disturbances. Reviewing thyroid function tests helps determine if the symptoms are related to inadequate thyroid hormone levels.
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A child with a known history of asthma is admitted to the hospital with a respiratory infection. Which action is the nurse's priority?
- A. Administer a nebulizer treatment as ordered.
- B. Perform chest physiotherapy.
- C. Monitor oxygen saturation levels closely.
- D. Educate the parents about infection prevention.
Correct Answer: A
Rationale: The priority in asthma management is ensuring the airways are open, which is best achieved by administering a nebulizer treatment as ordered.
Which statement by the mother of a child with rheumatic fever (RF) shows she has an understanding of prevention for her other children?
- A. Whenever one of them gets a sore throat, I will give that child an antibiotic.
- B. There is no treatment. It must run its course.
- C. If their culture is positive for group A streptococcus, I will give them their antibiotic.
- D. If their culture is positive for staphylococcus A, I will give them their antibiotic.
Correct Answer: A
Rationale: Preventive antibiotic therapy is indicated when a culture is positive for group A streptococcus, but unnecessary antibiotic use (if the infection is viral) should be avoided.
An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)
- A. Check his fingerstick glucose level
- B. Assess his skin temperature and moisture
- C. Measure his pulse and blood pressure
- D. Document anxiety on the surgical checklist
Correct Answer: C
Rationale: These actions help assess for hypoglycemia, a common issue in diabetic patients, and ensure appropriate intervention.
Which is a common, serious complication of rheumatic fever?
- A. Seizures
- B. Cardiac arrhythmias
- C. Pulmonary hypertension
- D. Cardiac valve damage
Correct Answer: D
Rationale: Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever.
Postoperative pulmonary hypertension can be managed with
- A. hyperventilation
- B. catecholamines
- C. nitroprusside
- D. phosphodiesterase inhibitors
Correct Answer: C
Rationale: Inhaled nitric oxide and phosphodiesterase inhibitors are commonly used to manage postoperative pulmonary hypertension.