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A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement?
- A. Begin preparing client for thyroidectomy procedure
- B. Space the client's care to provide periods of rest
- C. Assess the client for hyperactive bowel sounds
- D. Provide warm blankets to prevent heat loss
Correct Answer: B
Rationale: Rest is important for managing symptoms of hyperthyroidism, which can be exacerbated by stress and activity.
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It is reasonable to suspect child abuse in the following situations:
- A. 6-month old with a large scalp bruise
- B. 7-year-old girl who is found masturbating
- C. 2-year old with multiple bruises of different ages over the shins
- D. 3-month old with failure to thrive
Correct Answer: A
Rationale: The correct answer is A because a large scalp bruise in a 6-month-old is highly suspicious for abuse. The other options (b-e) are less indicative of abuse.
The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete?
- A. Manual dexterity and visual acuity
- B. Capillary refill time and radial pulse volume
- C. Deep tendon reflexes and skin color
- D. Skin elasticity and hand grip strength
Correct Answer: A
Rationale: Manual dexterity and visual acuity are important for the client to properly use the glucose meter.
In scabies:
- A. Itching is due to sensitisation by the mite
- B. Vesicles may be seen in children
- C. The organism is easily demonstrated
- D. Spread can occur through clothes and bedding
Correct Answer: A
Rationale: Itching in scabies is due to an allergic reaction to the mites and their products, leading to sensitization.
The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, “Why do my child’s fingertips look like that?†On what understanding does the nurse base a response?
- A. Clubbing occurs as a result of untreated congestive heart failure.
- B. Clubbing occurs as a result of a left-to-right shunting of blood.
- C. Clubbing occurs as a result of decreased cardiac output.
- D. Clubbing occurs as a result of chronic hypoxia.
Correct Answer: D
Rationale: Clubbing of the fingers develops in response to chronic hypoxia.
Dubowitz criteria to assess gestational age include:
- A. Skin colour
- B. Breast tissue
- C. Popliteal angle
- D. Moro reflex
Correct Answer: B
Rationale: Breast tissue is one of the criteria used in the Dubowitz assessment to estimate gestational age. Skin colour, popliteal angle, and Moro reflex are not part of the Dubowitz criteria.