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A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
- A. Lethargy
- B. Hypotension
- C. Decreased heart rate
- D. Increased temperature
Correct Answer: D
Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (A) is more indicative of hypothyroidism. Hypotension (B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (C) is also not a common manifestation as tachycardia is typically present in thyroid storm. Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.
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A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
- A. NG tube
- B. Tongue blade
- C. Wrist restraints
- D. Oral airway
Correct Answer: D
Rationale: The correct answer is D: Oral airway. During a seizure, a client may experience difficulty breathing due to their airway being obstructed. Placing an oral airway helps maintain a clear airway, ensuring adequate oxygenation. NG tube (A) is not relevant to managing seizures. Tongue blade (B) can cause injury during a seizure. Wrist restraints (C) are not appropriate and can increase the risk of injury.
A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
- A. Remove one of the weights.
- B. Tie knots in the ropes near the pulleys to shorten them.
- C. Increase the elevation of the affected extremity.
- D. Reapply the weights to ensure proper traction.
Correct Answer: D
Rationale: The correct answer is D: Reapply the weights to ensure proper traction. When the weights are resting on the floor, it means that there is no longer effective traction on the affected limb. To maintain proper skeletal traction, the weights should be suspended freely in the air. By reapplying the weights and ensuring they are hanging freely, the nurse can restore the necessary traction force to immobilize the fractured bone and facilitate healing. Removing a weight (choice A) may compromise the traction. Tying knots in the ropes (choice B) may alter the mechanics of the traction system. Increasing the elevation of the extremity (choice C) does not address the issue of the weights resting on the floor.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Intrinsic factor
- B. Uric acid
- C. Chloride level
- D. Creatinine kinase
Correct Answer: B
Rationale: The correct answer is B: Uric acid. In acute gout, there is an accumulation of uric acid crystals in the joints, leading to inflammation and pain. As a result, the uric acid levels in the blood increase. Monitoring uric acid levels helps in diagnosing and managing gout.
Explanation for other choices:
A: Intrinsic factor - Intrinsic factor is related to vitamin B12 absorption, not gout.
C: Chloride level - Chloride level is not directly impacted by acute gout.
D: Creatinine kinase - Creatinine kinase is an enzyme related to muscle breakdown, not specifically affected by gout.
A nurse is caring for a client who is experiencing an exacerbation of heart failure. Thenurse is
assessing the client 24 hr later. How should the nurse interpret the findings related to the
diagnosis of heart failure? For each finding, click to specify whe ther the finding is unrelated to
the diagnosis, a sign of potential improvement, or a sign of potential worsening condition. Diagnostic Results
Hgb 8.4 g/dL (12 to 18 g/dL)
Hct 42% (37% to 47%)
WBC count 9,800/mm3 (5,000 to 10,000/ mm3) Potassium 432
mEq/L (3.5 to 5 mEq/L)
- A. Lung sounds clean
- B. Creatinine 1.8 mm/dl
- C. Weight 113kg(249 lb)
- D. WBC Count 11,800mm3
- E. Temperature: 38.5°C (101.3°F)
- F. Shortness of breath with exertion
Correct Answer: A, B,C,D,E
Rationale:
The correct answer is A, B, C, D, E. In heart failure exacerbation, key indicators are related to fluid overload and organ perfusion. A) Lung sounds clean indicate potential improvement in pulmonary congestion. B) Creatinine 1.8 mm/dl is important for kidney function monitoring, as worsening kidney function can occur in heart failure. C) Weight 113kg reflects fluid retention, relevant for heart failure management. D) WBC count (11,800mm3) can indicate infection, which can worsen heart failure. E) Temperature 38.5°C can suggest infection or systemic inflammatory response, which worsens heart failure.
A nurse is caring for a client who has heart failure. Drag words from the choices below to fill
in each blank in the following sentence. The client is at risk for developing _________ and_________
Word choices: dysrhythmias, respiratory alkalosis, acute kidney injury, fluid volume
- A. Dysrhythmias
- B. Respiratory alkalosis
- C. Acute kidney injury
- D. Fluid volume deficit
Correct Answer: A
Rationale: The correct answer is A: Dysrhythmias. In heart failure, the reduced cardiac output can lead to inadequate perfusion, causing the heart to work harder, increasing the risk of dysrhythmias. Dysrhythmias are common in heart failure due to changes in the heart's structure and function. Respiratory alkalosis is less likely in heart failure as it is more commonly associated with conditions like hyperventilation. Acute kidney injury can occur in heart failure due to poor perfusion, but it is not directly related to the risk stated. Fluid volume deficit is not the typical risk in heart failure as patients usually have fluid retention.