Nokea
The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:
- A. Living in an area where the soil is depleted of iodine
- B. Eating foods that decrease the thyroxine level
- C. Using aluminum cookware to prepare the family's meals
- D. Taking medications that decrease the thyroxine level
Correct Answer: A
Rationale: Endemic goiter is caused by iodine deficiency, often due to low iodine levels in soil, leading to inadequate thyroid hormone production.
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A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:
- A. Draw a man in six parts
- B. Give his first and last name
- C. Dress without supervision
- D. Define a list of words
Correct Answer: B
Rationale: Per the Denver Developmental Screening Test, a 4-year-old should be able to give their first and last name, a milestone achievable despite developmental delays.
The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.
- A. check the dressing every 8 hours for excessive drainage
- B. assess the pupils for signs of increased intracranial pressure
- C. position the client flat with the head rotated away from the surgical site
- D. monitor the client's respiratory status, including rate and pattern of breathing
- E. notify the health care provider if the dressing is saturated or the client has more than 50 mL of drainage in 8 hours
Correct Answer: B, D, E
Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.
The nurse is caring for a client who fractured her leg in a motor vehicle accident. A cast is applied. The nurse will assess which of the following? Select all that apply.
- A. pulses
- B. capillary refill
- C. skin temperature
- D. squeeze the cast every hour to check for firmness
- E. assess for pain, numbness, tingling, or inability to move the toes
Correct Answer: A, B, C, E
Rationale: Assessing pulses, capillary refill, skin temperature, and neurovascular symptoms (pain, numbness, tingling, movement) ensures circulation and nerve function are intact; squeezing the cast is inappropriate.
A 68-year-old client states he decided not to take the herpes zoster (shingles) immunization because his friend had the immunization and still developed shingles. Which of the following information should the nurse include when discussing this issue with the client? Select all that apply.
- A. Shingles rarely occurs after immunization.
- B. The immunization decreases the severity of infection.
- C. The immunization decreases the likelihood of postherpetic syndrome.
- D. The immunization cuts the chance of developing shingles in half.
- E. The client should never take advice from friends.
Correct Answer: B,C,D
Rationale: The shingles vaccine reduces severity (B), postherpetic syndrome risk (C), and shingles incidence by about 50% (D). It doesn't eliminate risk (A), and dismissing friends' advice (E) is inappropriate.
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
- A. BP 146/88
- B. Respirations 28 shallow
- C. Weight gain of 10 pounds in 6 months
- D. Pink complexion
Correct Answer: B
Rationale: Tachypnea (respirations 28 shallow) is a common sign of anemia due to reduced oxygen-carrying capacity, prompting compensatory increased respiratory rate.