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The client has undergone a thyroidectomy, and the nurse is providing care. Which assessment finding requires immediate intervention?
- A. Hoarseness and a sore throat.
- B. Difficulty swallowing.
- C. Numbness and tingling around the mouth.
- D. Temperature of 100.2°F (37.9°C).
Correct Answer: C
Rationale: The correct answer is C: Numbness and tingling around the mouth. This finding indicates potential hypocalcemia, a common complication post-thyroidectomy due to inadvertent damage to parathyroid glands. Hypocalcemia can lead to tetany, seizures, and cardiac dysrhythmias. Immediate intervention is needed to prevent serious complications.
Hoarseness and a sore throat (A) are expected post-thyroidectomy due to intubation. Difficulty swallowing (B) can be due to swelling but is not immediately life-threatening. A temperature of 100.2°F (37.9°C) (D) is slightly elevated but not a priority in this scenario.
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A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?
- A. Elevated blood pressure.
- B. Fever and chills.
- C. Increased urine output.
- D. Bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Fever and chills. This indicates a transfusion reaction because it is a common symptom of hemolytic reactions, where the body is reacting to incompatible blood. Elevated blood pressure (A) is not typically a sign of a transfusion reaction. Increased urine output (C) is more likely a sign of fluid overload. Bradycardia (D) is not a common symptom of a transfusion reaction. Fever and chills are classic signs of a transfusion reaction due to the body's immune response to the blood transfusion.
A client with hypertension is receiving dietary education from a nurse. Which recommendation should the nurse include?
- A. Increase your intake of saturated fats.
- B. Limit your sodium intake to less than 2 grams per day.
- C. Avoid foods high in potassium.
- D. Consume at least three alcoholic beverages daily.
Correct Answer: B
Rationale: The correct answer is B: Limit your sodium intake to less than 2 grams per day. Sodium restriction is crucial in managing hypertension as it helps reduce blood pressure. Excessive sodium intake can lead to fluid retention and increased blood volume, worsening hypertension. This recommendation aligns with evidence-based guidelines for hypertension management.
Incorrect choices:
A: Increasing saturated fat intake is not recommended for hypertension, as it can lead to cardiovascular issues.
C: Avoiding foods high in potassium is not advised, as potassium helps regulate blood pressure.
D: Consuming alcoholic beverages daily can raise blood pressure and interfere with hypertension management.
A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?
- A. Decreased libido is a common side effect of SSRIs and may improve over time.
- B. I will notify your healthcare provider to discuss possible medication changes.
- C. You should take your medication with food to reduce side effects.
- D. Increase your daily exercise to help manage this side effect.
Correct Answer: B
Rationale: The correct response is B: I will notify your healthcare provider to discuss possible medication changes. This is the best choice because decreased libido is a common side effect of SSRIs that can significantly impact the client's quality of life. Consulting the healthcare provider is crucial to explore alternative treatment options or adjustments to improve the client's symptoms. Choices A, C, and D do not address the underlying issue of decreased libido and are unlikely to provide effective solutions. Choice A only acknowledges the side effect without offering a proactive solution. Choice C is unrelated to the sexual side effect and may not address the client's concerns. Choice D suggests a general lifestyle change that may not directly address the medication side effect. Consulting the healthcare provider for medication adjustments is the most appropriate action to address this specific side effect.
A client with chronic obstructive pulmonary disease (COPD) is experiencing respiratory distress. Which intervention should the nurse implement first?
- A. Administer bronchodilators as prescribed.
- B. Encourage pursed-lip breathing.
- C. Position the client in a high Fowler's position.
- D. Obtain a stat arterial blood gas (ABG) sample.
Correct Answer: C
Rationale: The correct answer is to position the client in a high Fowler's position first. This helps improve lung expansion and oxygenation, making it the priority intervention for a client with respiratory distress. Administering bronchodilators or obtaining an ABG sample can wait until the client's oxygenation is improved. Pursed-lip breathing can be helpful, but positioning is more critical in this situation.
The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?
- A. Hyperpigmentation of the skin.
- B. Hypotension.
- C. Moon face and buffalo hump.
- D. Weight loss.
Correct Answer: C
Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excessive cortisol production leads to characteristic symptoms like moon face (round, puffy face) and buffalo hump (fat accumulation at the back of the neck). This is due to redistribution of fat in the body. Hyperpigmentation (choice A) is seen in Addison's disease, not Cushing's. Hypotension (choice B) is unlikely due to the cortisol-induced sodium retention. Weight loss (choice D) is less common in Cushing's due to the metabolic changes causing weight gain.