Nokea
The signs of thyroid crisis resulting from Graves' disease include:
- A. constipation with gastric distension.
- B. bradycardia and bradypnea.
- C. hyperthermia and tachycardia.
- D. constipation and lethargy.
Correct Answer: C
Rationale: Thyroid crisis in Graves' disease typically presents with hyperthermia (high body temperature) and tachycardia (rapid heart rate). These symptoms are a result of excessive thyroid hormone production and can lead to life-threatening complications if not promptly addressed. Choices A, B, and D are incorrect because constipation with gastric distension, bradycardia and bradypnea, and constipation and lethargy are not typical signs of a thyroid crisis in Graves' disease.
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In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called:
- A. Aphasia.
- B. Agnosia.
- C. Sundowning.
- D. Confabulation.
Correct Answer: C
Rationale: The correct answer is C: Sundowning. Sundowning is a phenomenon where individuals with cognitive impairment experience increased confusion and agitation in the late afternoon or early evening. This often occurs in conditions like dementia. Choice A, Aphasia, refers to a language disorder affecting a person's ability to communicate. Choice B, Agnosia, is the inability to recognize objects. Choice D, Confabulation, is the production of false memories without the intention to deceive, often seen in conditions like Korsakoff's syndrome.
Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer's type and confabulates. The nurse understands that this client:
- A. Denies confusion by being jovial.
- B. Pretends to be someone else.
- C. Rationalizes various behaviors.
- D. Fills in memory gaps with fantasy.
Correct Answer: D
Rationale: Confabulation, a common symptom in dementia, involves filling in memory gaps with fabricated stories rather than intentionally pretending to be someone else (Choice B), denying confusion by being jovial (Choice A), or rationalizing various behaviors (Choice C). Confabulation is not a deliberate act but a memory error that results in the creation of false memories.
A woman is complaining that she feels like the room is spinning even though she is not moving. Which of the following is characteristic of benign positional vertigo?
- A. It usually occurs with a headache.
- B. Pupillary changes are common.
- C. It is usually triggered when the patient bends forward.
- D. Nystagmus continues even when the eyes fixate on an object.
Correct Answer: C
Rationale: The correct answer is C: 'It is usually triggered when the patient bends forward.' Benign positional vertigo is often triggered by changes in head position, such as bending forward. Choices A, B, and D are incorrect. A is incorrect because benign positional vertigo is not typically associated with headaches. B is incorrect because pupillary changes are not a common feature of benign positional vertigo. D is incorrect because nystagmus in benign positional vertigo usually stops when the eyes fixate on an object.
What is the most appropriate nursing diagnosis for the client's son based on the information provided?
- A. Risk for other-directed violence
- B. Disturbed sleep pattern
- C. Caregiver role strain
- D. Social isolation
Correct Answer: C
Rationale: The correct answer is 'Caregiver role strain.' In the scenario presented, the son expresses that his father's constant confusion, incontinence, and tendency to wander are intolerable. These challenges indicate that the son is experiencing strain in his role as a caregiver. 'Risk for other-directed violence' is not appropriate because there is no indication of violent behavior. 'Disturbed sleep pattern' is not the most relevant nursing diagnosis given the information provided. 'Social isolation' is not the most appropriate choice as the son's concerns are related to the challenges of caregiving, not isolation.
Which of the following birthmarks usually fade or regress as the child gets older?
- A. Hemangiomas
- B. Congenital dermal melanocytosis (i.e., Mongolian spots)
- C. Macular stains
- D. Hemangiomas, congenital dermal melanocytosis (i.e., Mongolian spots), and macular stains
Correct Answer: D
Rationale: The correct answer is D. Hemangiomas, congenital dermal melanocytosis (i.e., Mongolian spots), and macular stains are birthmarks that usually fade or regress as the child gets older. Hemangiomas are vascular birthmarks that often shrink and fade over time. Congenital dermal melanocytosis (Mongolian spots) are blue-gray birthmarks commonly found on the lower back and buttocks of infants, which typically fade by adolescence. Macular stains, also known as salmon patches, are pink or red birthmarks that usually fade within the first few years of life. Choice D is correct because all the mentioned birthmarks tend to diminish as the child grows, unlike choices A, B, and C which do not fade or regress with age.