Nokea
The nurse is caring for a client with a history of hypothyroidism. The nurse should expect the client to have:
- A. Fatigue
- B. Tachycardia
- C. Weight loss
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, causing fatigue, weight gain, and cold intolerance.
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The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:
- A. Alopecia is an unavoidable side effect.
- B. There are several wig makers for children.
- C. Most children select a favorite hat to protect their heads.
- D. His hair will grow back in a few months.
Correct Answer: D
Rationale: Alopecia has occurred, and knowing it is a side effect does not address their concern. Although true, it does not give them hope for the future. Although true, it does not provide them with information of the temporary nature of the situation. Knowing the hair will grow back provides comfort that the alopecia is temporary.
A 24-year-old client presents to the emergency department protesting 'I am God.' The nurse identifies this as a:
- A. Delusion
- B. Illusion
- C. Hallucination
- D. Conversion
Correct Answer: A
Rationale: A delusion is a false belief, such as claiming to be God, common in psychotic disorders.
Before giving methergine postpartum, the nurse should assess the client for:
- A. Decreased amount of lochial flow
- B. Elevated blood pressure
- C. Flushing
- D. Afterpains
Correct Answer: B
Rationale: Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. Flushing is not a side effect of methergine. Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
The nurse is caring for a client with a closed head injury. Which finding should be reported to the doctor immediately?
- A. Urine output of 50 mL per hour
- B. Blood pressure of 148/92
- C. Respiratory rate of 16 breaths per minute
- D. Pupils that are unequal
Correct Answer: D
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration in a head injury, requiring immediate reporting. The other findings are within normal or less urgent ranges.
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Providing him with books, challenging puzzles, and games as diversionary activities
- B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- C. Having a volunteer come in to sit with the client and to read him stories
- D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.