Nokea
The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?
- A. Risk for ineffective breathing pattern
- B. Risk for imbalanced body temperature
- C. Risk for decreased cerebral tissue perfusion
- D. Activity intolerance
Correct Answer: B
Rationale: Thyroid crisis (thyroid storm) causes hyperthermia, making imbalanced body temperature the priority due to the risk of life-threatening hypermetabolic complications.
You may also like to solve these questions
The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:
- A. Administer a bolus of IV fluid
- B. Administer pain medication
- C. Administer an antiemetic
- D. Allow the patient a chance to eat
Correct Answer: C
Rationale: Administering an antiemetic before chemotherapy prevents nausea and vomiting, common side effects of these drugs.
A 72-year-old client with Parkinson disease is recovering from pneumonia and is to be discharged, but he remains weak and has poor control of his hands because of tremors. A home health aide will visit three times weekly to assist the client to bathe, and his daughter will visit every evening after work to help with laundry and housework. Which of the following referrals is most indicated to allow the client to remain independent in his home?
- A. Home meal delivery program (Meals on Wheels)
- B. Friendly Visitors program
- C. Hospice
- D. Occupational therapist
Correct Answer: D
Rationale: An occupational therapist (D) can help with adaptive strategies for tremors, promoting independence. Meal delivery (A), visitors (B), and hospice (C) are less relevant.
The nurse is preparing to administer insulin to a client with type 1 diabetes mellitus. The client is to receive 10 units of regular insulin and 20 units of NPH insulin. Which of the following actions by the nurse is correct?
- A. Draw up the NPH insulin first, then the regular insulin in the same syringe.
- B. Administer the regular insulin in one syringe and the NPH in another.
- C. Mix the regular insulin with the NPH insulin in a vial before drawing it up.
- D. Administer the regular insulin 30 minutes after the NPH insulin.
Correct Answer: A
Rationale: regular insulin is drawn up first, followed by NPH, to prevent contamination of the regular insulin with NPH
The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:
- A. Pupillary changes
- B. Projectile vomiting
- C. Wheezing respirations
- D. Sudden, intense pain
Correct Answer: A
Rationale: After administering naloxone, the nurse should assess for pupillary changes, as reversal of opioid effects can cause sympathetic stimulation, affecting pupil size.
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
- A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
- B. The client who is six months pregnant with abdominal pain and the client with facial lacerations and a broken arm
- C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The pregnant client and the client with facial lacerations/broken arm have stable conditions suitable for sharing a room, unlike the other pairs with critical or incompatible needs.