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A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated?
- A. Trisodothyronine 3
- B. Phosphorus
- C. Calcium
- D. Thyroid-stimulating hormone
Correct Answer: A
Rationale: The correct answer is A: Trisodothyronine 3. In Graves' disease, there is excessive production of thyroid hormones, including triiodothyronine (T3). Elevated T3 levels are common in hyperthyroidism, which is a hallmark of Graves' disease. T3 is the active form of thyroid hormone and is responsible for regulating metabolism. Phosphorus, calcium, and thyroid-stimulating hormone levels are typically not elevated in Graves' disease. Phosphorus and calcium are more related to bone health and are usually within normal limits unless complications arise. Thyroid-stimulating hormone levels are usually suppressed in hyperthyroidism, including Graves' disease.
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A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
- A. Administer analgesic medication.
- B. Increase the room temperature.
- C. Cleanse the client's wounds.
- D. Start IV with a large-bore needle.
Correct Answer: D
Rationale: The correct answer is D: Start IV with a large-bore needle. This is the priority intervention because fluid resuscitation is crucial in managing burn injuries to prevent hypovolemic shock. Starting an IV line allows for prompt administration of fluids and medications. Administering analgesic medication (A) can wait until after fluid resuscitation. Increasing room temperature (B) is not a priority in burn management. Cleansing wounds (C) can be done after fluid resuscitation. Starting the IV line with a large-bore needle (D) takes precedence over other interventions to stabilize the client's condition.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (A) and distended abdomen (B) are more indicative of right-sided heart failure. Confusion (C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, and digestion should be minimized to reduce pancreatic enzyme secretion. Keeping the client on NPO status allows the pancreas to rest and reduces stimulation of enzyme production. Administering antihypertensive medications (A) is not directly related to pancreatitis care. Placing the client in a supine position (C) may not be comfortable and can exacerbate pain. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a priority in acute cases.
A nurse is providing discharge teaching to a client who had a bilateral architectomy. The nurse should instruct the client to expect which of the following symptoms?
- A. Hypoglycemia
- B. Increased libido
- C. Hot flashes
- D. Increased muscle mass
Correct Answer: A
Rationale: The correct answer is A: Hypoglycemia. After a bilateral adrenalectomy, the client will have decreased cortisol production, leading to adrenal insufficiency. This can result in hypoglycemia due to decreased glucose regulation. Increased libido (B) and increased muscle mass (D) are not typical symptoms following this procedure. Hot flashes (C) are more commonly associated with menopause.
A nurse is caring for a client who has a full chest, which of the following actions should the nurse take?
- A. Inpatient fluid reduction
- B. Provide humidified oxygen
- C. Admonitor antibiotic medication
- D. Administer acute/micoplasm (café)
Correct Answer: B
Rationale: The correct answer is B: Provide humidified oxygen. This is because the client with a full chest may be experiencing difficulty breathing, and humidified oxygen can help improve oxygenation and relieve respiratory distress. Inpatient fluid reduction (choice A) is not indicated without further assessment. Admonitor antibiotic medication (choice C) is not directly related to addressing the client's respiratory distress. Administering acute/micoplasm (café) (choice D) is not a recognized medical intervention. Providing humidified oxygen is the most appropriate initial action to address the client's respiratory symptoms.