Nokea
The nurse is caring for a client who had a subtotal thyroidectomy yesterday. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a sore throat when I swallow.
- B. My legs feel cramped and tingly.
- C. I feel like my heart is skipping beats.
- D. I feel sleepy all the time.
Correct Answer: B
Rationale: Muscle cramps and tingling in the legs post-thyroidectomy suggest hypocalcemia, a serious complication due to possible parathyroid gland damage, which regulates calcium. This requires immediate assessment and intervention. Options A, C, and D are less urgent: sore throat is expected, palpitations may indicate hyperthyroidism, and sleepiness is nonspecific.
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A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B
Rationale: Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate.
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about hurting myself.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
A client had a radical mastectomy for cancer in her right breast.
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
- A. Position the client on her left side with her right arm protected in a sling.
- B. Position the client on her right side with her right arm elevated.
- C. Position the client in semi-Fowler's position with her right arm elevated.
- D. Position the client in the prone position with her right arm elevated.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that the client
- A. Should remain on bed rest in a semi-Fowler's position
- B. Should alternate ambulation with bed rest with legs elevated
- C. May ambulate and sit in chair as tolerated
- D. May ambulate as tolerated and remain in semi-Fowlers position in bed
Correct Answer: B
Rationale: Should alternate ambulation with bed rest with legs elevated. Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites.
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.