Nokea
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.
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A nurse is caring for a client who has a terminal diagnosis and states, 'I am ready to update my will.' The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?
- A. Denial
- B. Acceptance
- C. Anger
- D. Bargaining
Correct Answer: B
Rationale: The correct answer is B: Acceptance. The client expressing readiness to update their will indicates acceptance, one of the stages of grief according to Kubler-Ross. This stage involves coming to terms with the reality of the situation and making necessary preparations. Denial (choice A) involves refusing to accept the diagnosis, anger (choice C) involves feelings of frustration and unfairness, and bargaining (choice D) involves seeking ways to avoid the inevitable. In this scenario, the client's statement aligns with the acceptance stage, as they are taking practical steps to prepare for the future.
A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?
- A. Cataracts
- B. Diabetic retinopathy
- C. Macular degeneration
- D. Glaucoma
Correct Answer: A
Rationale: The correct answer is A: Cataracts. Cataracts cause a cloudy, opaque area over the lens of the eye, leading to blurred vision. This occurs due to the clouding of the lens from protein buildup. Diabetic retinopathy, choice B, involves damage to blood vessels in the retina due to diabetes. Macular degeneration, choice C, affects the central part of the retina leading to distortion or loss of central vision. Glaucoma, choice D, is characterized by increased pressure within the eye damaging the optic nerve. In this scenario, the cloudy, opaque area over the lens specifically points towards cataracts, making it the correct choice.
A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?
- A. Decreased peripheral pulses
- B. Heart rate 108/min
- C. Respiratory rate 10 breaths/min
- D. Dilated pupils
Correct Answer: B
Rationale: The correct answer is B: Heart rate 108/min. When a client has a fever (oral temperature of 39 C), the body responds by increasing the heart rate to help circulate blood more efficiently and maintain oxygen delivery to tissues. This compensatory mechanism is known as tachycardia. Decreased peripheral pulses (A) would not be expected as the body tries to increase circulation. Respiratory rate of 10 breaths/min (C) is extremely low and not consistent with fever. Dilated pupils (D) are not directly related to fever.
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?
- A. The client reports dizziness when ambulating to the bathroom
- B. The client reports having trouble sleeping the previous night
- C. The client ate 60% of their breakfast
- D. The client has a urine output of 400 mL for the past 8 hr
Correct Answer: A
Rationale: The correct answer is A. Dizziness when ambulating can be a sign of orthostatic hypotension, a potential side effect of antihypertensive medication. The nurse should further assess for signs of hypotension before administering the medication. Choices B, C, and D are less relevant to antihypertensive medication administration. Reporting trouble sleeping, eating 60% of breakfast, and having a urine output of 400 mL are not direct contraindications for administering antihypertensive medication.
A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration?
- A. Trough
- B. Peak
- C. Half-life
- D. Toxic
Correct Answer: A
Rationale: The correct answer is A: Trough. The trough level represents the lowest serum concentration of a medication in the body, usually measured just before the next dose is administered. This is important in monitoring the effectiveness and safety of the drug. Peak levels (B) indicate the highest concentration. Half-life (C) refers to the time it takes for half of the drug to be eliminated from the body. Toxic levels (D) are when the drug concentration is too high and can lead to harmful effects. Other choices are not relevant to the lowest serum concentration.