Nokea
Physical findings commonly seen in hypothyroidism include:
Coarse hair, thin brittle nails
- A. Malnourished appearance, alopecia
- B. Tachycardia, hyperreflexia
- C. Confusion, stupor
Correct Answer: A
Rationale: Coarse hair and thin brittle nails are classic signs of hypothyroidism due to decreased metabolic rate.
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The patient is admitted to the emergency department and was brought to the unit due to poor diabetic management. The wife asks how they can learn better. They have previously been to a diabetic class without much success.
Which of the following nursing strategy will be appropriate for the client?
- A. Arrange a meeting with the health care team.
- B. Have a one-on-one diabetic teaching with the client.
- C. Refer the client and wife to group diabetic teaching class.
- D. Discuss the possibility of having to stay longer in the unit to manage the blood sugar.
Correct Answer: B
Rationale: One-on-one teaching allows tailored education to address specific learning needs.
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client's:
- A. Level of consciousness
- B. Gag reflex
- C. Urinary output
- D. Movement of extremities
Correct Answer: B
Rationale: Assessing the gag reflex is critical post-esophagoscopy to ensure the client can swallow safely, as local anesthesia may impair this reflex.
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
- A. Expected
- B. Rude
- C. Professional
- D. Enjoyable
Correct Answer: B
Rationale: Rude. Native Americans consider direct eye contact to be impolite or aggressive among strangers.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
- A. Chills
- B. Scant lochia rubra
- C. Thirst and fatigue
- D. Temperature of 100.2°F (37.9°C)
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°C) also are common at 24 hours postpartum.
B.C underwent skin grafting. Vital signs are BP 124/68; HR 100 bpm; RR 24; T 37.7 °C.
Potential complication that can be possibly developed will be:
- A. Sepsis
- B. Hypovolemic
- C. Pain
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Infection, such as sepsis, is a serious complication of skin grafting due to the risk of microbial invasion at the graft site.