Nokea
A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?
- A. Constipation
- B. Sensitivity to cold
- C. Weight gain of 4.5 kg (10 lbs) in 3 weeks
- D. Frequent mood changes
Correct Answer: D
Rationale: The correct answer is D: Frequent mood changes. In hyperthyroidism, there is an excessive production of thyroid hormones leading to symptoms such as irritability, anxiety, and mood swings. This is due to the increased metabolic activity caused by the excess thyroid hormones. Constipation (A) is more common in hypothyroidism. Sensitivity to cold (B) is also seen in hypothyroidism due to decreased metabolic rate. Weight gain of 4.5 kg (10 lbs) in 3 weeks (C) is unlikely in hyperthyroidism as it usually leads to weight loss. Therefore, choice D is the most appropriate manifestation for hyperthyroidism.
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A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
- A. Turn the client every 4 hours.
- B. Brush the client’s teeth with a suction toothbrush every 12 hours.
- C. Provide humidity by maintaining moisture within the ventilator tubing.
- D. Position the head of the client’s bed in the flat position.
Correct Answer: B
Rationale: The correct answer is B: Brush the client's teeth with a suction toothbrush every 12 hours. This action helps reduce the risk of ventilator-associated pneumonia by preventing the buildup of bacteria in the oral cavity that could be aspirated into the lungs. Ventilator-associated pneumonia is often caused by bacteria from the oral cavity entering the respiratory system. Regular oral care, including brushing the teeth, helps to reduce the bacterial load in the mouth. Turning the client every 4 hours (choice A) helps prevent pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia. Providing humidity in the ventilator tubing (choice C) is important for maintaining airway moisture but does not specifically target pneumonia prevention. Positioning the head of the client's bed flat (choice D) is important for proper ventilation but does not address oral care and bacterial buildup.
A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
- A. Plan of care changes for the upcoming shift
- B. Intracranial pressure readings
- C. Glasgow results
- D. Code status
Correct Answer: D
Rationale: The correct answer is D: Code status. In the background segment of SBAR, the nurse should include the client's code status to ensure the oncoming nurse is aware of the client's wishes in case of a medical emergency. This information is crucial for providing appropriate care and making decisions aligned with the client's preferences. Intracranial pressure readings (B) and Glasgow results (C) are more specific to the current condition of the client and would be included in the assessment segment of SBAR. Plan of care changes for the upcoming shift (A) would be part of the recommendation segment.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Distorted perceptual field.
- B. Urinary frequency.
- C. Rapid speech.
Correct Answer: C
Rationale: The correct answer is C: Rapid speech. In clients with moderate anxiety, rapid speech is a common finding due to the increased arousal and nervousness associated with anxiety. The individual may talk quickly as a way to cope with their anxiety. Distorted perceptual field (A) is more indicative of severe anxiety or psychosis. Urinary frequency (B) is not a typical finding in moderate anxiety, unless there are underlying medical issues. Rapid speech (C) aligns with the increased arousal and restlessness seen in moderate anxiety.