Nokea
The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
- A. exophthalmos and conjunctival redness
- B. flushed, warm, moist skin
- C. systolic murmur at the left sternal border
- D. decreased body temperature and cold intolerance
Correct Answer: D
Rationale: The correct assessment findings to stay alert for when evaluating for hypothyroidism are decreased body temperature and cold intolerance. Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to a decrease in metabolic rate. This can result in symptoms such as feeling cold all the time and a lower body temperature. Therefore, the nurse should keep an eye out for these symptoms during the assessment of a client being evaluated for hypothyroidism. Symptoms such as exophthalmos and conjunctival redness are more commonly associated with hyperthyroidism.
You may also like to solve these questions
In preparing a preschool-aged patient for an injection, the most appropriate nursing intervention is to:
- A. allow the patient to administer an injection to a doll.
- B. arrange for the patient to watch a peer receive an injection.
- C. have the parents explain the process to the patient.
- D. suggest diversionary activities like singing.
Correct Answer: A
Rationale: Allowing the child to practice on a doll can help reduce anxiety and prepare them for the procedure.
Which finding would you expect in a 4-week-old with biliary atresia?
- A. Abdominal distention, enlarged liver and spleen, clay-colored stools, and tea-colored urine.
- B. Abdominal distention with bruises and hematuria.
- C. Yellow sclera/skin, oily skin, and prolonged bleeding times.
- D. No manifestations until advanced disease.
Correct Answer: A
Rationale: Biliary atresia typically presents with hepatosplenomegaly, pale stools, and dark urine due to impaired bile excretion.
The nurse is developing a teaching plan for a patient. Which of the following is a modifiable risk factor for the development of hypertension? i.Race iv.Sedentary lifestyle ii.High cholesterol v.Age iii.Cigarette smoking
- A. 1 and 2
- B. 2, 3, 4 and 5
- C. 2, 3 and 4
- D. All of the above
Correct Answer: C
Rationale: High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for the development of hypertension. Race and age are non-modifiable risk factors. By targeting high cholesterol, cigarette smoking, and promoting physical activity, the nurse can help the patient reduce their risk of developing hypertension. It is important to focus on these modifiable factors in the teaching plan to empower the patient to make positive lifestyle changes and improve their overall health.
You are evaluating a 6-year-old male child with Langerhans cell histiocytosis (LCH); the parents state that the most common site of bone involvement is
- A. skull
- B. vertebra
- C. mandible
- D. pelvis
Correct Answer: A
Rationale: Skull is the most common site of bone involvement in LCH.
When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
- A. Urinary output of 30 ml in an hour
- B. Central venous pressure reading of 2 cm H20
- C. Pulse rates of 120 and 110 in a 15- minute period
- D. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
Correct Answer: A
Rationale: The observation that indicates adequate tissue perfusion to vital organs is a urinary output of 30 ml in an hour. Adequate tissue perfusion is essential to ensure that vital organs receive enough blood and oxygen. Monitoring urinary output is a crucial indicator of perfusion status, as it reflects the perfusion of the kidneys. A urinary output of at least 30 ml/hour or more indicates that the kidneys are receiving sufficient blood flow and are able to produce urine, which helps in removing waste products from the body. In this case, a urinary output of 30 ml in an hour suggests adequate tissue perfusion to vital organs. The other options do not directly reflect tissue perfusion to vital organs and may indicate inadequate perfusion or compromised hemodynamic status.