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The nurse is caring for a client with Grave's disease. Which finding would indicate a complication of the client's disease?
- A. Extreme fatigue
- B. Increased heart rate
- C. Shortness of breath
- D. Urinary frequency
Correct Answer: C
Rationale: Shortness of breath may indicate thyroid storm, a life-threatening complication of Grave's disease. Fatigue and increased heart rate are common symptoms, and urinary frequency is unrelated.
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Because an adult is scheduled for a cystoscopy, the nurse should plan to do which of the following immediately prior to the procedure?
- A. Keep the client NPO for eight hours
- B. Ask the client about claustrophobia
- C. Ask the client about allergies to shellfish
- D. Encourage fluids
Correct Answer: C
Rationale: Cystoscopy may involve iodine-based contrast; shellfish allergies suggest iodine sensitivity, requiring verification. NPO is not needed, claustrophobia is irrelevant, and fluids are not prioritized immediately before.
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
- A. Oral ingestion
- B. Topical contact
- C. Inhalation
- D. Eye splashes
Correct Answer: A
Rationale: Oral ingestion. Young children are most likely to ingest toxic substances due to their exploratory behavior.
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will the nurse expect to be included in the teaching plan?
- A. TV or telephone use will not be allowed while the implant is in place.
- B. A Foley catheter is usually inserted.
- C. A high fiber diet is recommended.
- D. Excretions will be considered radioactive.
Correct Answer: B
Rationale: A catheter allows urine elimination without possible disruption of the implant. There is usually no restriction on TV or phone use, so answer A is incorrect. The client is placed on a low residue diet, so answer C is incorrect. The client's radiation is not internal; therefore, there are no special precautions with excretions, making answer D incorrect.
An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?
- A. Ask the pregnant daughter to leave the room and have the wife assist in holding the client.
- B. Have the client wear a lead apron over his chest and abdomen.
- C. Close the door to the room securely during the x-ray.
- D. Ask the wife and daughter to leave the room.
Correct Answer: D
Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.
The nurse in the outpatient clinic is caring for assigned clients with type 1 diabetes mellitus. Which client should the nurse recognize as having the highest risk of developing hypoglycemia?
- A. 29-year-old client with new-onset influenza
- B. 40-year-old client who is a cyclist and is training for an upcoming race
- C. 65-year-old client with cellulitis of the right leg
- D. 72-year-old client with emphysema who is receiving prednisone
Correct Answer: D
Rationale: Prednisone increases blood glucose, but abrupt cessation or dose changes can cause hypoglycemia in type 1 diabetes due to insulin sensitivity. Influenza, exercise, and cellulitis pose risks, but prednisone’s metabolic impact is greatest.