Nokea
The nurse is caring for a client eight hours postoperative following a total thyroidectomy. Which of the following assessment findings indicate that the client is developing a complication?
- A. Moderate amount of dried sanguineous drainage on the dressing
- B. Oral temperature of 99.2°F (37.3°C)
- C. Apical pulse of 56
- D. The client reports a sore throat when speaking
Correct Answer: A
Rationale: Excessive drainage post-thyroidectomy may indicate hemorrhage, a serious complication. A slightly elevated temperature, mild bradycardia, and sore throat are expected or less concerning in the immediate postoperative period.
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The nurse has provided medication instruction to a client who has been prescribed metformin. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching?
- A. This medication may cause me to have bloating or loose stools.
- B. I will need to take my blood glucose prior to taking this medication.
- C. If I eat fewer carbohydrates in a day, I should skip a dose.
- D. The goal of this medication is to increase my hemoglobin A1C.
Correct Answer: A
Rationale: Metformin commonly causes gastrointestinal side effects like bloating or loose stools. Blood glucose checks are not required before dosing, skipping doses is inappropriate, and metformin aims to lower, not increase, HbA1c.
The nurse is interviewing a client taking prescribed methimazole for hyperthyroidism. Which assessment finding requires notification to the physician?
- A. body mass index (BMI) 23
- B. sore throat
- C. pulse (P) 84
- D. skin rash
Correct Answer: B
Rationale: Sore throat may indicate agranulocytosis, a rare but serious methimazole side effect, requiring immediate physician notification. BMI 23, pulse 84, and skin rash are less urgent unless severe.
The nurse is assessing a client with pheochromocytoma. Which of the following would be an expected finding?
- A. hyperglycemia
- B. hypertension
- C. ataxia
- D. oliguria
- E. headache
Correct Answer: A, B, E
Rationale: Pheochromocytoma releases catecholamines, causing hyperglycemia, hypertension, and headaches. Ataxia and oliguria are not typical findings.
The nurse is caring for a client with a confirmed pregnancy in her first trimester with hyperthyroidism. The nurse anticipates the physician will prescribe
- A. levothyroxine
- B. calcitriol
- C. methimazole
- D. propylthiouracil (PTU)
Correct Answer: D
Rationale: Propylthiouracil (PTU) is preferred in the first trimester of pregnancy for hyperthyroidism due to lower teratogenic risk compared to methimazole. Levothyroxine treats hypothyroidism, and calcitriol manages calcium levels.
The nurse is assessing a client with diabetes mellitus type 2. Which of the following findings would be consistent with a diagnosis of diabetes mellitus type 2?
- A. Fasting blood glucose level 110 mg/dL (6.1 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L]
- B. Hemoglobin A1c (HbA1c) level 7.5% [ < 5.7%]
- C. Elevated Serum Insulin Levels
- D. Presence of ketones in the urine
Correct Answer: B
Rationale: HbA1c of 7.5% indicates poor long-term glucose control, consistent with type 2 diabetes (diagnosis: ≥6.5%). Fasting glucose at 110 mg/dL is borderline, elevated insulin reflects resistance, and ketones are more typical of type 1 or DKA.