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During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply.
- A. Cortisol
- B. Thyroid
- C. Estrogen
- D. Testosterone
Correct Answer: B
Rationale: Increased BMR with elevated temperature suggests thyroid (B) excess (hyperthyroidism), boosting metabolism. Cortisol (A) affects stress, not BMR primarily. Estrogen (C) and testosterone (D) influence other systems. B is correct. Rationale: Thyroid hormones (T3, T4) directly raise BMR and heat, a classic endocrine imbalance, per physiology, unlike other hormones with indirect effects.
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When providing holistic care to a client, the nurse recognizes that which behaviors are necessary?
- A. Understand and respect each person's definition of health
- B. Understand and respect each person's responses to illness
- C. Focus on a standard definition of health and beliefs
- D. Instruct the client that health is an inactive process
Correct Answer: A
Rationale: Holistic care in nursing embraces the whole person mind, body, spirit requiring tailored approaches. Understanding and respecting each person's definition of health acknowledges their unique values, like viewing wellness as independence or spiritual peace, shaping care plans. Respecting responses to illness honors individual coping like stoicism or seeking support fostering trust. A standard health definition ignores this diversity, risking alienation, while calling health inactive contradicts its dynamic nature people actively pursue it. Holistic nursing uses models like the wellness wheel to integrate dimensions, ensuring care fits the client, not a mold. This flexibility enhances engagement, as when a nurse adapts teaching for a client valuing herbal remedies, strengthening outcomes by aligning with personal beliefs and experiences.
The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?
- A. Arranging for the wheelchair
- B. Asking her family to visit
- C. Assisting her to sit out of bed in a chair qid
- D. Encouraging the use of an overhead trapeze
Correct Answer: D
Rationale: The trapeze promotes upper body strength and mobility, aiding recovery.
Mr. Gary named his wife to make decisions if he can't. This is an example of?
- A. Health care proxy
- B. Living will
- C. Patient education
- D. Care transition
Correct Answer: A
Rationale: Naming his wife for decisions is a health care proxy (A) chosen surrogate, per definition. Living will (B) states wishes, education (C) teaches, transition (D) moves not proxy-specific. A fits Mr. Gary's delegation of authority, making it correct.
Palpating the midclavicular line is the correct technique for assessing
- A. Baseline vital signs
- B. Systolic blood pressure
- C. Respiratory rate
- D. Apical pulse
Correct Answer: D
Rationale: The midclavicular line locates the apical pulse at the heart's apex.
A patient develops red eyes 2 days after an episode of malaria probable cause is:
- A. Conjunctivitis
- B. Anterior uveitis
- C. Viral keratitis
- D. Endophthalmitis
Correct Answer: B
Rationale: Red eyes post-malaria suggest an ocular complication. Conjunctivitis (choice A) causes redness but isn't typically linked to malaria unless secondary infection occurs. Anterior uveitis (choice B), inflammation of the iris and ciliary body, is a rare but documented malaria sequel, possibly from immune response or parasite-related damage, presenting with redness, pain, and photophobia. Viral keratitis (choice C) affects the cornea and is unrelated to malaria. Endophthalmitis (choice D), a severe intraocular infection, is unlikely without trauma or surgery. B is correct, as anterior uveitis aligns with malaria's systemic inflammatory effects. Nurses should assess eye symptoms, refer to ophthalmology, and manage pain, preventing vision loss in such cases.