Nokea
A nurse notes that a clients eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?
- A. Decreased TSH levels
- B. Increased T4 levels
- C. Elevated calcium levels
- D. Low hemoglobin levels
Correct Answer: B
Rationale: The nurse should expect increased T4 levels in a client with slightly protruding eyes, known as exophthalmos, as it is a classic sign of hyperthyroidism, where the thyroid gland is overactive. Thyroid hormones, such as T4, are responsible for regulating metabolism, and elevated levels can lead to symptoms like exophthalmos. Decreased TSH levels (choice A) would actually be seen in primary hyperthyroidism due to negative feedback. Elevated calcium levels (choice C) are more indicative of hyperparathyroidism. Low hemoglobin levels (choice D) are not typically associated with exophthalmos or hyperthyroidism.
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A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?
- A. Encourage the client to eat independently with utensils.
- B. Provide finger food at mealtime.
- C. Feed the client only pureed foods.
- D. Offer the client fluids only between meals.
Correct Answer: B
Rationale: The correct answer is B: Provide finger food at mealtime. This option is appropriate for a client with dementia as it promotes independence and encourages self-feeding, which can help maintain their dignity and autonomy. Finger foods are easy to handle and reduce the risk of frustration or confusion that may arise from using utensils. Encouraging self-feeding also helps stimulate cognitive function and maintain motor skills.
A: Encouraging the client to eat independently with utensils may be challenging and frustrating for someone with dementia.
C: Feeding the client only pureed foods may not be necessary if the client is able to eat regular food safely.
D: Offering fluids only between meals may lead to dehydration, especially for clients who may forget to ask for fluids when needed.
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
- A. Surgical drain output 300 mL during an 8-hr shift
- B. Bounding peripheral pulses
- C. Neck vein distention
- D. Weight gain of 2 kg (4.4 lb) in 24 hours
Correct Answer: A
Rationale: The correct answer is A: Surgical drain output 300 mL during an 8-hr shift. This finding indicates potential fluid loss, which can lead to fluid volume deficit. Surgical drain output is a direct measure of fluid loss from the body and can help assess the client's fluid status. Bounding peripheral pulses (B) and neck vein distention (C) are signs of fluid volume excess, not deficit. Weight gain of 2 kg (4.4 lb) in 24 hours (D) suggests fluid retention, not deficit.
A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain?
- A. Right lower quadrant
- B. Left lower quadrant
- C. Upper left quadrant
- D. Mid-epigastric area
Correct Answer: B
Rationale: The correct answer is B: Left lower quadrant. Diverticular disease commonly causes pain in the left lower quadrant due to inflammation or infection of the diverticula, small pouches that can develop in the colon wall. This area corresponds to the location of the descending and sigmoid colon, where most diverticula occur. Pain in the right lower quadrant (choice A) is more indicative of appendicitis. Upper left quadrant pain (choice C) is more likely related to conditions involving the spleen or stomach. Mid-epigastric pain (choice D) is typically associated with issues related to the stomach or pancreas.
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Iron-deficiency anemia
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Iron-deficiency anemia. Dumping syndrome following a gastric resection can lead to rapid emptying of the stomach contents into the small intestine, causing malabsorption of nutrients, especially iron. Iron-deficiency anemia can develop due to inadequate iron absorption. Monitoring for anemia is crucial in these clients.
Hyperkalemia (A), hypoglycemia (B), and hypertension (D) are not typical complications of dumping syndrome. Hyperkalemia is high potassium levels, hypoglycemia is low blood sugar, and hypertension is high blood pressure, which are not directly associated with dumping syndrome.
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Implementing airborne precautions involves placing the client in a negative pressure room, using an N95 respirator, and ensuring proper ventilation. Standard precautions (A) are used for all clients. Contact precautions (C) are used for clients with infections that can be spread by direct or indirect contact. Droplet precautions (D) are used for infections spread through larger respiratory droplets. In this case, airborne precautions are specifically needed due to the mode of transmission of tuberculosis.