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The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
- A. Graves' disease.
- B. Cushing's syndrome.
- C. Addison's disease.
- D. Hypothyroidism.
Correct Answer: A
Rationale: The correct answer is A, Graves' disease. The symptoms described in the client are classic manifestations of hyperthyroidism, which is commonly caused by Graves' disease, an autoimmune condition affecting the thyroid. Weight loss, racing heart rate, difficulty sleeping, moist skin with fine hair, prominent eyes, lid retraction, and a staring expression are all indicative of hyperthyroidism. Choice B, Cushing's syndrome, is characterized by weight gain, hypertension, and a rounded face due to excess cortisol. Choice C, Addison's disease, presents with symptoms such as weight loss, fatigue, and hyperpigmentation due to adrenal insufficiency. Choice D, hypothyroidism, typically features symptoms opposite to those described in the client, such as weight gain, bradycardia, and dry skin.
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During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?
- A. provide the client with 4 ounces of orange juice
- B. call 911 to summon emergency assistance
- C. check the client for lacerations or fractures
- D. assess the client's blood sugar level
Correct Answer: C
Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.
A nurse starts classes for clients with type 2 diabetes. Which information would the nurse use as an outcome evaluation for the class?
- A. Parking convenience for attendees continues to be a major concern.
- B. Fasting blood glucose average readings were 20% lower by the end of classes.
- C. Discussion of food exchanges and calories was a well-attended class.
- D. Demonstrating the use of a blood glucose meter was an effective teaching strategy.
Correct Answer: B
Rationale: A reduction in fasting blood glucose levels indicates the effectiveness of the diabetes management education provided. Monitoring blood glucose levels is a crucial aspect of diabetes management, and a decrease in average readings signifies improvement in managing blood sugar levels. Choices A, C, and D are not direct outcome evaluations related to the effectiveness of the education provided in managing diabetes. Parking convenience, attendance, and teaching strategies are not direct indicators of the impact on the clients' health outcomes.
A community health nurse is evaluating the effectiveness of a recent smoking cessation program. Which outcome indicates success?
- A. increased attendance at support group meetings
- B. reduced number of cigarettes smoked per day
- C. higher sales of nicotine replacement products
- D. lower relapse rate among participants
Correct Answer: D
Rationale: The correct answer is D: lower relapse rate among participants. A lower relapse rate indicates that participants are successfully quitting smoking and maintaining their cessation, which is the ultimate goal of a smoking cessation program. Increased attendance at support group meetings (choice A) may demonstrate engagement but does not necessarily indicate successful smoking cessation. Similarly, higher sales of nicotine replacement products (choice C) may reflect increased product usage but not necessarily successful smoking cessation. While reducing the number of cigarettes smoked per day (choice B) is a positive change, it does not guarantee successful smoking cessation or long-term abstinence.
A public health nurse is addressing the issue of childhood lead poisoning in a low-income community. Which intervention should be prioritized?
- A. Providing free blood lead level testing for children
- B. Distributing pamphlets on the dangers of lead exposure
- C. Conducting home inspections for lead-based paint
- D. Educating parents about lead poisoning prevention
Correct Answer: A
Rationale: Providing free blood lead level testing for children should be prioritized as it directly identifies children who are at risk and in need of intervention. This intervention allows for early detection and timely implementation of necessary measures to prevent further lead exposure or address existing poisoning. Distributing pamphlets (choice B) may raise awareness but does not directly identify at-risk children. Conducting home inspections (choice C) is important but may not be as immediate and targeted as blood lead level testing. Educating parents (choice D) is essential but may not directly identify and address individual cases of lead poisoning as testing does.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?
- A. Hypertension.
- B. Diabetes mellitus.
- C. Inadequate lifestyle changes in diet and exercise.
- D. Increased risk of chronic illnesses.
Correct Answer: C
Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.