Nokea
The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for:
- A. Anorexia.
- B. Tachycardia.
- C. Weight gain.
- D. Cold skin.
Correct Answer: B
Rationale: Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.
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Which of the following nursing interventions will be most effective when caring for a client who is experiencing powerlessness?
- A. Make certain that all staff members focus only on the client's capabilities.
- B. Encourage family members to become more responsible for the client's care.
- C. Request a referral to a psychologist.
- D. Include the client in decision making whenever possible.
Correct Answer: D
Rationale: Including the client in decision-making empowers them, reducing feelings of powerlessness by restoring a sense of control.
The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? Select all that apply.
- A. Administer the medication as a 2-mg bolus.
- B. Give the medication undiluted in incremental doses.
- C. Be alert for shivering and hypotension.
- D. Use only a free-flowing I.V. line in a large vein.
- E. Monitor the client's level of consciousness.
Correct Answer: B,C,D,E
Rationale: Flumazenil is given undiluted in incremental doses (B), via a free-flowing IV line (D), with monitoring for side effects like shivering and hypotension (C) and level of consciousness (E). A 2-mg bolus (A) is incorrect, as flumazenil is titrated in smaller doses.
A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
- A. You won't be alone; we'll ensure someone is with you.
- B. Everyone dies alone, but it's not something to fear.
- C. Let's focus on keeping you comfortable instead.
- D. Have you considered spiritual counseling?
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
- A. Cut around blood stains to remove clothing.
- B. Place each item of clothing in a separate paper bag.
- C. Allow clothing to dry.
- D. Refrain from documenting client statements.
- E. Place bullets in a sterile container.
Correct Answer: B
Rationale: To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.