Nokea
If a client is suffering from thyroid storm, the PN can expect to find on assessment:
- A. tachycardia and hyperthermia.
- B. bradycardia and hypothermia.
- C. a large goiter.
- D. a calm, quiet client
Correct Answer: A
Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed. Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter. Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.
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A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
- A. Check with the case manager on duty about possible police intervention.
- B. Provide an environment of concern and emotional stabilization.
- C. Clean the patient's wounds with normal saline and gauze.
- D. Refer the patient to a counselor specializing in trauma.
Correct Answer: B
Rationale: In a situation where a patient describes a brutal assault and rape, the first priority should be to provide emotional support and create a safe and supportive environment. This helps the patient feel secure and cared for, which is crucial for their well-being at that moment. Checking with the case manager about police intervention should come after ensuring the patient's immediate emotional needs are addressed. Cleaning the patient's wounds, though important, can be secondary to providing emotional stabilization. Referring the patient to a counselor specializing in trauma is also crucial for long-term support, but the immediate focus should be on providing emotional support and stability.
A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of Glucose and Hemoglobin
- C. ECG
- D. CT scan
Correct Answer: A
Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.
A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. What action should the nurse take?
- A. Tell the mother to decrease the daily number of feedings because the weight gain is excessive.
- B. Tell the mother that the infant's weight is increasing as expected.
- C. Tell the mother that the infant should continue with breast milk as the weight gain is adequate.
- D. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes.
Correct Answer: B
Rationale: The correct answer is to inform the mother that the infant's weight gain is normal. Infants typically double their birth weight by 6 months, which is precisely the case here, with the infant's weight increasing from 6 lb 8 oz to 13 lb. This weight gain indicates healthy growth and development. Therefore, there is no need to decrease feedings. The infant should continue with breast milk as it is providing adequate nutrition. Additionally, introducing semisolid foods is usually recommended between 4 and 6 months of age, so there is no indication to delay based on the infant's weight gain.
A nurse working in a surgical unit notices a patient experiencing SOB, calf pain, and warmth over the posterior calf. All of these symptoms may indicate which of the following medical conditions?
- A. Patient may have a DVT.
- B. Patient may be exhibiting signs of dermatitis.
- C. Patient may be in the late stages of CHF.
- D. Patient may be experiencing anxiety after surgery.
Correct Answer: A
Rationale: The correct answer is that the patient may have a DVT (Deep Vein Thrombosis). SOB (Shortness of Breath), calf pain, and warmth over the posterior calf are classic signs and symptoms of DVT. DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs. Choices B, C, and D are incorrect because dermatitis does not typically present with these symptoms, late stages of CHF would manifest with other signs, and anxiety after surgery usually does not produce these specific symptoms.
Which of the following arterial blood gas values indicates a patient may be experiencing a condition of metabolic acidosis?
- A. PaO2 90 mm Hg
- B. Bicarbonate 15 mEq/L
- C. CO2 47 mm Hg
- D. pH 7.34
Correct Answer: B
Rationale: The correct answer is B: Bicarbonate 15 mEq/L. In metabolic acidosis, the bicarbonate levels are lower than normal. A bicarbonate value of 15 mEq/L indicates a deficit in the buffer system, contributing to the acidosis. Choices A, C, and D are incorrect. Choice A, PaO2 90 mm Hg, reflects oxygen partial pressure and is not directly related to metabolic acidosis. Choice C, CO2 47 mm Hg, represents carbon dioxide levels and is more indicative of respiratory status. Choice D, pH 7.34, falls within the normal range (7.35-7.45) and does not confirm metabolic acidosis.