Nokea
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift,the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?
- A. Medicate the patient with antipsychotics.
- B. Assist the client to the correct room.
- C. Move the client to a room at the end of the hall.
- D. Place the client in restraints.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the correct room. This is the appropriate action as it addresses the immediate issue of the client being in the wrong room, which is causing distress to the other client. Moving the client to the correct room ensures safety and comfort for both clients. Medicating with antipsychotics (choice A) is not the first-line intervention in this situation and should be avoided unless absolutely necessary due to potential side effects. Moving the client to a room at the end of the hall (choice C) may not address the underlying issue and can isolate the client unnecessarily. Placing the client in restraints (choice D) should be avoided as it can be traumatic and is not indicated in this scenario.
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A nurse is educating a 28-year-old female client about the impacts of hypothyroidism on overall health. Which of the following statements would the nurse include in the teaching?
- A. If you become pregnant, low thyroid hormone levels can affect your developing fetus.
- B. Hypothyroidism can cause autoimmune disorders over time.
- C. Low thyroid hormone levels will cause your metabolism to speed up and heart rate to increase.
- D. Low blood pressure is usually associated with hypothyroidism.
Correct Answer: A
Rationale: Rationale: The correct answer is A because hypothyroidism, characterized by low thyroid hormone levels, can lead to complications during pregnancy, affecting fetal development. This is due to the essential role of thyroid hormones in fetal brain and nervous system development.
Summary of Incorrect Choices:
B: Hypothyroidism is linked to autoimmune disorders, not a consequence of it.
C: Hypothyroidism actually slows down metabolism and heart rate due to decreased thyroid hormone levels.
D: Low blood pressure is more commonly associated with hyperthyroidism, where the thyroid is overactive.
A nurse is obtaining a health history from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?
- A. Confusion
- B. Fatigue
- C. Pain
- D. Slurred speech
Correct Answer: B
Rationale: The correct answer is B: Fatigue. In iron deficiency anemia, the body lacks enough iron to produce hemoglobin, leading to decreased oxygen delivery to tissues, resulting in fatigue. Confusion (A) is not a typical finding. Pain (C) is not a direct symptom of iron deficiency anemia. Slurred speech (D) is more commonly associated with neurological conditions. In summary, fatigue is a hallmark symptom of iron deficiency anemia due to decreased oxygen delivery, making it the expected finding.
A nurse is providing teaching to a client about hypothyroidism. Which of the following potentially fatal conditions associated with hypothyroidism will the nurse include?
- A. Myxedema coma
- B. Goiters
- C. Sjogren's syndrome
- D. Hashimoto's disease
Correct Answer: A
Rationale: The correct answer is A: Myxedema coma. In hypothyroidism, untreated individuals can develop myxedema coma, a severe condition characterized by extreme hypothyroidism leading to decreased mental status, hypothermia, and respiratory depression, which can be fatal if not promptly treated. Myxedema coma is a medical emergency requiring immediate intervention.
B: Goiters are enlarged thyroid glands and are not typically fatal.
C: Sjogren's syndrome is an autoimmune disorder affecting moisture-producing glands, not directly related to hypothyroidism.
D: Hashimoto's disease is an autoimmune condition causing hypothyroidism but does not lead to myxedema coma.
A nurse is caring for a client who reports increased anxiety and nervousness,heat intolerance,and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH),elevated thyroxine (T4) and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?
- A. Hypotension
- B. Tachycardia
- C. Slow respiratory rate
- D. Decreased body temperature
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. In this scenario, the client is showing symptoms of hyperthyroidism, such as increased anxiety, nervousness, heat intolerance, and unintentional weight loss. The decreased TSH and elevated T4/T3 levels indicate an overactive thyroid gland.
Tachycardia is a common symptom of hyperthyroidism due to the increased metabolic rate caused by excess thyroid hormones. The body's response to the increased metabolism is to speed up the heart rate to meet the increased demand for oxygen and nutrients. Therefore, the nurse can anticipate tachycardia in this client.
The other options are incorrect because hypotension is not typically associated with hyperthyroidism; slow respiratory rate is not a common vital sign abnormality seen in hyperthyroidism; decreased body temperature is unlikely as hyperthyroidism usually causes heat intolerance and increased body temperature.
A nurse is caring for a client who has sickle cell anemia. The client asks,Why do I feel so tired and fatigued all of the time? Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have fewer red blood cells.
- C. You have an autoimmune disease.
- D. You have a low ferritin level.
Correct Answer: B
Rationale: Correct Answer: B - You have fewer red blood cells.
Rationale: In sickle cell anemia, the abnormal hemoglobin causes red blood cells to become rigid, sticky, and crescent-shaped, leading to decreased oxygen delivery. This results in anemia, leading to fatigue and tiredness. Choice A is incorrect as it does not directly relate to the pathophysiology of sickle cell anemia. Choice C is unrelated to the client's symptoms. Choice D is not specific to the underlying cause of fatigue in sickle cell anemia.