Nokea
The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Administer a stool softener.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent rest periods. For a client with hyperthyroidism, rest is crucial to conserve energy and support the body's recovery. Hyperthyroidism is characterized by increased metabolic rate, leading to fatigue and weakness. Rest periods help reduce metabolic demands and prevent exhaustion. A high-calorie diet (choice A) may be necessary to support increased metabolism but is not the priority. Restricting fluid intake (choice C) can lead to dehydration, which should be avoided in hyperthyroidism. Administering a stool softener (choice D) is unrelated to managing hyperthyroidism.
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A client with a history of myocardial infarction (MI) is prescribed atorvastatin (Lipitor). Which outcome indicates that the medication is effective?
- A. Increased blood pressure.
- B. Lowered cholesterol levels.
- C. Decreased heart rate.
- D. Improved liver function.
Correct Answer: B
Rationale: The correct answer is B: Lowered cholesterol levels. Atorvastatin is a statin medication used to lower cholesterol levels, reducing the risk of further cardiovascular events in patients with a history of MI. Lowering cholesterol helps prevent plaque buildup in arteries, reducing the likelihood of another MI. Increased blood pressure (A) and decreased heart rate (C) are not direct indicators of atorvastatin's effectiveness. Improved liver function (D) may be a consideration due to potential side effects, but the primary goal of atorvastatin is to lower cholesterol levels to prevent cardiovascular events.
A client with chronic renal failure is prescribed erythropoietin (Epogen). Which outcome indicates that the medication is effective?
- A. Increased urine output.
- B. Improved hemoglobin levels.
- C. Decreased blood pressure.
- D. Stable potassium levels.
Correct Answer: B
Rationale: The correct answer is B: Improved hemoglobin levels. Erythropoietin stimulates the production of red blood cells, leading to an increase in hemoglobin levels. This is the desired outcome in a client with chronic renal failure, as it helps alleviate anemia.
Choice A is incorrect because increased urine output is not a direct indicator of erythropoietin effectiveness. Choice C is incorrect as erythropoietin does not directly impact blood pressure. Choice D is incorrect because stable potassium levels are not a primary outcome of erythropoietin therapy in chronic renal failure.
A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?
- A. Elevated blood pressure.
- B. Fever and chills.
- C. Increased urine output.
- D. Bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Fever and chills. This indicates a transfusion reaction because it is a common symptom of hemolytic reactions, where the body is reacting to incompatible blood. Elevated blood pressure (A) is not typically a sign of a transfusion reaction. Increased urine output (C) is more likely a sign of fluid overload. Bradycardia (D) is not a common symptom of a transfusion reaction. Fever and chills are classic signs of a transfusion reaction due to the body's immune response to the blood transfusion.
A client with newly diagnosed diabetes mellitus is receiving teaching on foot care. Which instruction should the nurse include?
- A. Walk barefoot whenever possible to toughen your feet.
- B. Soak your feet in hot water daily to improve circulation.
- C. Trim your toenails straight across to prevent ingrown toenails.
- D. Use a heating pad to keep your feet warm.
Correct Answer: C
Rationale: Correct Answer: C - Trim your toenails straight across to prevent ingrown toenails.
Rationale:
1. Trimming toenails straight across helps prevent ingrown nails.
2. Ingrown nails can lead to infection, especially risky for diabetics due to poor wound healing.
3. Walking barefoot toughens feet, increasing risk of injury.
4. Soaking in hot water can cause burns or skin damage.
5. Using a heating pad can lead to burns or decreased sensation in feet, increasing injury risk.
Summary:
Option C is correct as it directly addresses a common issue in diabetic foot care - ingrown toenails. Options A, B, and D pose risks of injury or damage to the feet, which is detrimental for diabetic individuals.
A client with a history of asthma is prescribed salmeterol (Serevent). Which instruction should the nurse provide?
- A. Use this medication for acute asthma attacks.
- B. Use this medication before using your albuterol inhaler.
- C. Use this medication twice daily for long-term control.
- D. Use this medication as needed for wheezing.
Correct Answer: C
Rationale: The correct instruction is C: Use this medication twice daily for long-term control. Salmeterol is a long-acting beta-agonist used for maintenance therapy in asthma to provide long-term control of symptoms and prevent exacerbations. It should not be used for acute asthma attacks as it does not provide quick relief like rescue inhalers such as albuterol (choice A). It is not meant to replace albuterol, so it should not be used before using albuterol (choice B). Using salmeterol as needed for wheezing (choice D) is not appropriate as it is a maintenance medication and not a rescue medication.