Nokea
The patient with hypothyroidism
The patient with hypothyroidism will most likely experience which of the following?
- A. Diarrhea and weight gain.
- B. Warm skin and brittle nails.
- C. Dry skin and weight gain.
- D. Constipation and tachycardia.
Correct Answer: C
Rationale: Hypothyroidism causes dry skin and weight gain due to slowed metabolism.
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The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?
- A. Deficient fluid volume
- B. Disturbed body image
- C. Risk for impaired skin integrity
- D. Risk for ineffective health maintenance
Correct Answer: A
Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.
Liquid iron preparation
Liquid iron preparation, which of the following directions would be appropriate for the nurse to teach?
- A. Administer at least one hour before meals.
- B. Inform the patient about the loose stools.
- C. Liquid iron must be taken with a straw.
- D. Avoid juices with iron.
Correct Answer: C
Rationale: Using a straw prevents tooth staining from liquid iron.
During a home visit, the nurse observes a man who is recovering from a left total hip replacement. Which observation indicates that the client understands his care?
- A. He is sitting in a soft, overstuffed easy chair.
- B. He bends over to pat his cat.
- C. He crosses his legs when sitting.
- D. He holds the cane in his right hand when walking.
Correct Answer: D
Rationale: Holding the cane in the right hand (opposite the affected left hip) provides support and balance, indicating proper care understanding. Soft chairs, bending, or crossing legs risk hip dislocation.
Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia who is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
A patient with major depressive disorder is prescribed fluoxetine (Prozac). Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Avoid drinking grapefruit juice.
- C. It may take several weeks to feel the full effect.
- D. Stop taking the medication if you feel better.
Correct Answer: C
Rationale: Fluoxetine’s full effect takes 4–6 weeks, and patients must continue it to maintain benefits. Bedtime dosing is not standard, grapefruit juice is irrelevant, and stopping early risks relapse.