Nokea
The nurse identifies the client problem 'risk for imbalanced body temperature' for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care?
- A. Discourage the use of an electric blanket.
- B. Assess the client's temperature every two (2) hours.
- C. Keep the room temperature cool.
- D. Space activities to promote rest.
Correct Answer: A
Rationale: Hypothyroidism causes cold intolerance; discouraging electric blankets prevents burns due to reduced sensation. Frequent temperature checks, cool rooms, and rest are less relevant.
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The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care?
- A. Diarrhea due to gastrointestinal (GI) hypermotility
- B. Imbalanced nutrition due to insufficient calorie intake
- C. Activity intolerance due to increased metabolic rate
- D. Anxiety due to forgetfulness and slowed speech
Correct Answer: D
Rationale: Forgetfulness and slowed speech that occur with hypothyroidism can cause the client to be anxious.
The nurse discusses the long-term effects of diabetes mellitus with the client and realizes that the client needs further teaching when the client identifies which occurrence as a complication of this disease?
- A. Blindness
- B. Stroke
- C. Renal failure
- D. Liver failure
Correct Answer: D
Rationale: Liver failure is not a common complication of diabetes, unlike blindness, stroke, and renal failure.
The client with type 2 DM is scheduled for cardiac rehabilitation exercises (cardiac rehab). The nurse notes that the client's blood glucose level is 300 mg/dL and that the urine is positive for ketones. How should the nurse proceed?
- A. Send the client to cardiac rehab; exercise will lower the client's glucose level.
- B. Give insulin; send the client for exercises with a 15-gram carbohydrate snack.
- C. Delay cardiac rehab; blood glucose levels will decrease too much with exercise.
- D. Cancel cardiac rehab; blood glucose levels will increase further with exercise.
Correct Answer: D
Rationale: Exercising with blood glucose levels exceeding 250 mg/dL and ketonuria increases the secretion of glucagon, growth hormone, and catecholamines, causing the liver to release more glucose.
When the nurse teaches the client how to self-administer potassium iodide (Lugol's solution), which instruction is most appropriate?
- A. Swallow the drug quickly.
- B. Take the drug before meals.
- C. Dilute the drug in fruit juice.
- D. Chill the drug before taking it.
Correct Answer: C
Rationale: Diluting potassium iodide in fruit juice improves palatability and reduces gastric irritation.
The nurse identified a concept of metabolism for a client diagnosed with diabetes. Which antecedent would be identified as placing the client at risk for diabetes?
- A. Nutrition.
- B. Sensory perception.
- C. pH regulation.
- D. Medication.
Correct Answer: A
Rationale: Poor nutrition (e.g., high sugar intake) is a key risk factor for diabetes, impacting metabolism. Sensory, pH, and medications are less directly causative.