Nokea
The nurse is assessing a client with suspected hyperthyroidism. Which of the following symptoms is most likely to be present?
- A. Weight gain.
- B. Cold intolerance.
- C. Tremors.
- D. Constipation.
Correct Answer: C
Rationale: Tremors are a common symptom of hyperthyroidism due to increased metabolic rate and nervous system stimulation.
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A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
- A. Asterixis.
- B. Hypotension.
- C. Polyuria.
- D. Bradycardia.
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
- A. Hypoglycemia.
- B. Hypercalcemia.
- C. Hypermagnesemia.
- D. Hyperbilirubinemia.
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication?
- A. Impotence
- B. Mood swings
- C. Increased appetite
- D. Complete atrioventricular (AV) block
Correct Answer: A
Rationale: A common side effect of beta-adrenergic blocking agents, such as metoprolol, is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects occur rarely and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and complete AV block are not reported side effects.
The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what should be the nurse's next priority?
- A. Monitor for sharp epigastric pain.
- B. Give warm gargles for sore throat.
- C. Check for a return of the gag reflex.
- D. Monitor for complaints of heartburn.
Correct Answer: C
Rationale: The nurse places highest priority on assessing for the return of the gag reflex, which is part of maintaining the client's airway. The nurse should also monitor the client for sharp pain (may indicate a potential complication) and heartburn. The client would receive warm gargles, but this cannot be done until the gag reflex has returned.
A client 6 weeks postpartum is asking the nurse about taking progesterone (Depo-Provera) for birth control. Which of the following should the nurse determine? Select all that apply.
- A. If the client has a sexually transmitted disease.
- B. How willing her husband is to have her take the drug.
- C. If the woman is experiencing postpartum depression.
- D. That the woman is not currently pregnant.
- E. If the woman is breast-feeding.
Correct Answer: C,D,E
Rationale: The nurse should assess for postpartum depression, pregnancy status, and breast-feeding, as these affect Depo-Provera's safety and efficacy. STDs and husband's willingness are not primary concerns.