Nokea
A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?
- A. Decreased body temperature
- B. Increased incisional drainage
- C. Hypertension
- D. Bradycardia
Correct Answer: C
Rationale: Hypertension is correct. Thyroid storm is a severe, acute exacerbation of hyperthyroidism, and it is associated with hypertension, tachycardia, fever, and other symptoms of sympathetic nervous system overactivity.
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A nurse is reinforcing teaching with a client who has a new prescription for a testosterone patch. Which of the following instructions should the nurse include?
- A. Apply the patch to the scrotum.
- B. Remove the patch after 12 hours.
- C. Apply the patch to the upper arm.
- D. Leave the patch on for 48 hours.
Correct Answer: C
Rationale: Applying the testosterone patch to the upper arm (or other recommended sites) ensures effective hormone absorption.
A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Tell the staff members to stop their discussion.
- C. Participate in an in-service about client confidentiality.
- D. Speak to the staff members in private about client confidentiality.
Correct Answer: B
Rationale: Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client's medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client's privacy is respected.
A nurse is caring for an adolescent who states, 'I joined the track and field team, so I won't argue with my brothers anymore.' The nurse should identify that the client is using which of the following defense mechanisms?
- A. Denial
- B. Sublimation
- C. Regression
- D. Repression
Correct Answer: B
Rationale: Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
A nurse is reinforcing teaching with a client who is scheduled for a cardiac catheterization. Which of the following instructions should the nurse include?
- A. Fast for 6 hours before the procedure.
- B. Drive yourself home after the procedure.
- C. Expect to stay overnight routinely.
- D. Avoid lying flat after the procedure.
Correct Answer: A
Rationale: Fasting for 6 hours before a cardiac catheterization reduces the risk of aspiration during sedation.
A nurse is caring for a client who has a new prescription for gabapentin. Which of the following adverse effects should the nurse monitor for?
- A. Drowsiness
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Gabapentin commonly causes drowsiness, which can affect the client's alertness and safety.