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The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?
- A. Increased TSH
- B. Increased thyroxine (T4)
- C. Decreased TSH
- D. Decreased T3
Correct Answer: A
Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.
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An older adult client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
- A. Recent compliance with prescribed medications.
- B. Sleep patterns during the previous few weeks.
- C. History of smoking over the past 6 months.
- D. Activity level prior to the onset of symptoms.
Correct Answer: A
Rationale: The correct answer is A: Recent compliance with prescribed medications. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts the management of the condition and could contribute to the current presentation. Ensuring that the client has been taking their prescribed medications can provide vital information to guide further treatment. Choices B, C, and D, although important in a comprehensive assessment, are not as immediately crucial as assessing medication compliance in this emergency situation.
The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?
- A. Breath sounds are audible bilaterally
- B. Mist is visible in the T-piece
- C. Pulse oximetry of 88
- D. Client is unable to verbalize
Correct Answer: C
Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.
An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?
- A. Have the UAP recheck the pulse and report back.
- B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
- C. Call the healthcare provider for further instructions.
- D. Immediately call the healthcare provider and prepare for transfer to critical care.
Correct Answer: B
Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client's cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.
After completing her first chemotherapy treatment, what behavior indicates that a female client with breast cancer understands her discharge care needs?
- A. She refuses to take anti-nausea medication.
- B. She rents movies and borrows books to pass time at home.
- C. She plans to resume strenuous physical activity immediately.
- D. She reports severe fatigue and inability to perform daily activities.
Correct Answer: B
Rationale: Renting movies and borrowing books for use during recovery indicates the client is planning restful activities at home, which aligns with appropriate post-chemotherapy care. Choices A, C, and D are incorrect because refusing anti-nausea medication can lead to complications, resuming strenuous physical activity immediately can be harmful, and reporting severe fatigue and inability to perform daily activities may indicate a need for medical attention rather than understanding discharge care needs.
A client on long-term corticosteroid therapy for rheumatoid arthritis presents with weakness and hypotension. What is the nurse's first action?
- A. Administer a PRN dose of corticosteroids.
- B. Place the client in a supine position.
- C. Encourage oral fluid intake.
- D. Review the client's recent medication history.
Correct Answer: A
Rationale: Administering a PRN dose of corticosteroids is the correct first action when a client on long-term corticosteroid therapy presents with weakness and hypotension. In this scenario, the client is likely experiencing adrenal insufficiency due to prolonged corticosteroid use. Administering corticosteroids promptly can help correct this insufficiency and improve the client's symptoms. Placing the client in a supine position may be necessary for symptomatic hypotension, but addressing the root cause with corticosteroids is more crucial initially. Encouraging oral fluid intake is important for many conditions but is not the priority in this case. Reviewing the client's recent medication history can provide valuable information but is not the first action needed to address the client's current presentation.