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The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
- A. Cheyne-Stokes respirations
- B. Kussmaul respirations
- C. Biot respirations
- D. Diaphragmatic respirations
Correct Answer: A
Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.
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A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- A. Impaired physical mobility related to decreased endurance
- B. Hypothermia r/t decreased metabolic rate
- C. Disturbed thought processes r/t interstitial edema
- D. Decreased cardiac output r/t bradycardia
Correct Answer: D
Rationale: Bradycardia in hypothyroidism can lead to decreased cardiac output, which is life-threatening and thus the highest priority diagnosis.
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 nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient’s nutritional status has improved after 4 days?
- A. The patient eats most of the food served to her.
- B. The patient has gained 1 pound since admission.
- C. The patient’s albumin level is 4.0 mg/dL.
- D. The patient’s hemoglobin is 8.5 g/dL.
Correct Answer: C
Rationale: albumin levels are best indicators of long-term nutritional status
The nurse finds a client smoking marijuana in the hospital and tells her that no smoking or use of drugs is allowed in the facility. The client responds by shouting, 'What business is it of yours? Leave me alone!' Which of the following initial responses is the best for the nurse to use to defuse the situation?
- A. It's my business because I'm your nurse.'
- B. If you don't put that out immediately, I will call security.'
- C. You are violating the facility policies and the law!'
- D. I'm sorry, but I have to ask you again to put out your marijuana cigarette.'
Correct Answer: D
Rationale: A calm, polite request to stop (D) de-escalates the situation while reinforcing the rule. Other responses (A, B, C) are confrontational and likely to escalate the client's agitation.
To decrease the likelihood of seizures and visual hallucinations in a client with alcohol withdrawal, the nurse should:
- A. Keep the room darkened by pulling the curtains
- B. Keep the light over the bed on at all times
- C. Keep the room quiet and dim the lights
- D. Keep the television or radio turned on
Correct Answer: C
Rationale: A quiet, dimly lit room reduces sensory stimulation, decreasing the risk of seizures and hallucinations during alcohol withdrawal.