Nokea
An adult had a thyroidectomy under local anesthesia and is now in the postanesthesia care unit. Which finding is of most concern to the nurse?
- A. The client complains of a sore throat.
- B. The client's hand involuntarily clenches when the nurse checks the blood pressure.
- C. The client is sitting upright in the bed.
- D. The client asks for a drink of water.
Correct Answer: B
Rationale: Involuntary hand clenching (Trousseau's sign) suggests hypocalcemia from parathyroid damage during thyroidectomy, a serious complication requiring immediate attention. Sore throat, upright position, or thirst are less urgent.
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The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.
The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
- A. Complaints of numbness and tingling in feet
- B. Wheezing noted when lung sounds auscultated
- C. Excessive perspiration
- D. Difficulty sleeping
Correct Answer: A
Rationale: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
- A. Speak directly to the interpreter while presenting information and use pauses for questions
- B. Talk to the interpreter in advance and leave the client and interpreter alone
- C. Include a family member and direct communications to that person
- D. Face the client while presenting the information as the interpreter talks in the native language
Correct Answer: D
Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.
The nurse is assessing a client's emotional state and coping strategies. Evidence of which behavior is of most concern to the nurse?
- A. Anxiety
- B. Dysfunctional family unit
- C. Social isolation
- D. Self-mutilation
Correct Answer: D
Rationale: Self-mutilation indicates severe emotional distress and risk of harm, the most concerning behavior requiring immediate intervention.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.