Nokea
A client with thyrotoxicosis says to the nurse, 'I am so irritable. I am having problems at work because I lose my temper very easily.' Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
- A. Your behavior is caused by your not following the medical regimen.'
- B. Your behavior is caused by the effects of the disease on your thyroid.'
- C. Your behavior is caused by your not accepting your diagnosis.'
- D. Your behavior is caused by the effects of the disease on your emotional stability.'
Correct Answer: B
Rationale: Thyrotoxicosis, due to excess thyroid hormone, increases metabolism and can affect the nervous system, leading to irritability and emotional lability. This explains the client's behavior as a direct result of the disease's impact on thyroid function.
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A client post-amputation is experiencing depression. Which nursing action is most appropriate?
- A. Administer an antidepressant immediately.
- B. Encourage participation in a support group.
- C. Limit discussions about the amputation.
- D. Schedule a physical therapy session.
Correct Answer: B
Rationale: Encouraging participation in a support group fosters emotional coping and peer support.
The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information?
- A. Excessive intake of dairy products makes constipation more common.'
- B. Immobility increases calcium absorption from the intestine.'
- C. Lack of weight bearing causes demineralization of the long bones.'
- D. Dairy products likely will contribute to weight gain.'
Correct Answer: C
Rationale: Immobility leads to bone demineralization, increasing calcium release and risk of hypercalcemia.
The nurse is caring for a client with suspected retinal detachment. Which of the following manifestations would not be consistent with a diagnosis of retinal detachment?
- A. Seeing 'floaters' in the field of vision
- B. A sense of having a curtain drawn over the eyes
- C. Flashes of light
- D. Intense pain in the affected eye
Correct Answer: D
Rationale: Retinal detachment typically presents with floaters, a curtain-like shadow, and flashes of light due to the retina pulling away from the underlying tissue. Intense pain is not a common symptom, as retinal detachment is usually painless.
Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma?
- A. Cough productive of yellow sputum.
- B. Bilateral expiratory wheezing.
- C. Chest tightness.
- D. Respiratory rate of 30 breaths/minute.
Correct Answer: A
Rationale: A productive cough with yellow sputum suggests a respiratory infection, which can exacerbate asthma. Wheezing, chest tightness, and tachypnea are typical asthma symptoms, not specific to infection.
The nurse is caring for a client in the emergency department who has overdosed on morphine. Which medication does the nurse anticipate to be ordered to reverse the effects of morphine?
- A. sodium bicarbonate
- B. flumazenil
- C. diphenhydramine
- D. naloxone
Correct Answer: D
Rationale: Naloxone is an opioid antagonist used to reverse morphine overdose effects, such as respiratory depression.