Nokea
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Weight gain
- C. Hypertension
- D. Decreased deep tendon reflexes
Correct Answer: D
Rationale: Corrected Rationale: Decreased deep tendon reflexes are a common finding in clients with hypothyroidism due to slowed metabolic processes. The other choices, such as bradycardia (slow heart rate), weight gain, and hypertension (high blood pressure) are not typically associated with hypothyroidism. Bradycardia can occur due to the decreased metabolic rate, but it is not a consistent finding. Weight gain is common but not universal, and hypertension is more commonly associated with hyperthyroidism.
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A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?
- A. Stoma that is red and moist
- B. Purulent drainage from the stoma
- C. Stoma that is dry and purple
- D. Mild swelling around the stoma
Correct Answer: C
Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.
A client with osteoporosis is being taught by a nurse about preventing bone loss. Which of the following instructions should the nurse include?
- A. Take a calcium supplement once a day.
- B. Avoid weight-bearing exercises.
- C. Walk for 30 minutes 3 times per week.
- D. Increase intake of high-phosphorus foods.
Correct Answer: C
Rationale: The correct answer is C: 'Walk for 30 minutes 3 times per week.' Walking is a weight-bearing exercise that helps prevent bone loss and improve overall health in clients with osteoporosis. Option A is incorrect because while calcium is essential for bone health, simply taking a supplement is not sufficient for preventing bone loss. Option B is incorrect because weight-bearing exercises are actually beneficial for improving bone density and strength. Option D is incorrect because high-phosphorus foods do not play a significant role in preventing bone loss in osteoporosis.
A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of canned vegetables.
- B. I will limit my daily sodium intake to 2 grams.
- C. I will increase my intake of whole grains.
- D. I will reduce my intake of processed meats.
Correct Answer: D
Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.
A nurse is reviewing the results of an arterial blood gas analysis of a client who has chronic obstructive pulmonary disease. Which of the following results should the nurse expect?
- A. PaO2 of 95 mm Hg
- B. PaCO2 of 55 mm Hg
- C. HCO3 of 24 mEq/L
- D. pH level of 7.35
Correct Answer: B
Rationale: In chronic obstructive pulmonary disease, there is impaired gas exchange, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. A PaCO2 of 55 mm Hg is higher than the normal range (35-45 mm Hg) and is indicative of respiratory acidosis in COPD. Choices A, C, and D are not typically associated with COPD. PaO2 may be decreased, HCO3 may be elevated to compensate for acidosis, and pH may be lower than 7.35 due to respiratory acidosis in COPD.
What is the best intervention for a patient with constipation?
- A. Administer a stool softener
- B. Encourage fluid intake
- C. Provide a high-fiber diet
- D. Administer a laxative
Correct Answer: B
Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.