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For a client with Graves' disease, which nursing intervention promotes comfort?
- A. Restricting intake of oral fluids
- B. Placing extra blankets on the client's bed
- C. Limiting intake of high-carbohydrate foods
- D. Maintaining room temperature in the low-normal range
Correct Answer: D
Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
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Two days postpartum a patient who had a C-section delivery complains of pain in the right leg.
The nurse should instruct the patient to
- A. apply warm compresses.
- B. massage the affected area.
- C. encourage range of motion exercises to promote circulation.
- D. maintain bed rest and notifies the physician.
Correct Answer: D
Rationale: Leg pain post-C-section may indicate a deep vein thrombosis, requiring bed rest and physician notification.
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.
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
- A. 14 minutes
- B. 10 minutes
- C. 15 minutes
- D. 9 minutes
Correct Answer: C
Rationale: 15 minutes. Frequency is measured from the start of one contraction to the start of the next.
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
When explaining the therapeutic regimen of vitamin B12 for pernicious anemia to a patient the nurse should explain that:
- A. Weekly Z-track injections are required for control.
- B. Daily intramuscular injections are required for control.
- C. Intramuscular injections once a month will maintain control.
- D. Oral tablets of vitamin B12 taken daily will keep the symptoms under control.
Correct Answer: C
Rationale: Monthly B12 injections maintain control in pernicious anemia due to absorption deficits.
An adult is scheduled for a cardioversion next week. What should the nurse plan to include when teaching the client about the procedure?
- A. The client should be NPO for eight hours before the procedure.
- B. The client will be awake during the procedure.
- C. The procedure will probably need to be repeated every month for at least six months.
- D. The procedure is usually done for life-threatening dysrhythmias such as ventricular fibrillation.
Correct Answer: A
Rationale: Cardioversion requires sedation, so the client must be NPO for 8 hours to prevent aspiration. The client is sedated, not awake, it's not typically repeated monthly, and it's used for atrial arrhythmias, not ventricular fibrillation.