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When assessing a client for an endocrine dysfunction, which question should the nurse ask?
- A. "Have you noticed any pain in your legs when walking?"
- B. "Have you had any unexplained weight loss?"
- C. "Have you noticed any change in your bowel movements?"
- D. "Have you experienced any joint pain or discomfort?"
Correct Answer: B
Rationale: The correct answer is B: "Have you had any unexplained weight loss?" Unexplained weight loss can be a common symptom of various endocrine disorders, such as hyperthyroidism and diabetes. This weight loss is often despite an adequate or increased appetite. Choices A, C, and D are less likely to be directly associated with endocrine dysfunction. Pain in the legs when walking could be related to musculoskeletal issues, changes in bowel movements may suggest gastrointestinal concerns, and joint pain is more commonly linked to rheumatologic conditions rather than primary endocrine disorders.
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Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client's medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?
- A. Explain to the client that it is too early to have an injection for pain
- B. Call the practitioner, report the client's symptoms, and obtain further orders
- C. Reposition the client for greater comfort and turn on the television as a distraction
- D. Prepare the injection and administer it to the client early because of the severe pain
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is option B: Call the practitioner, report the client's symptoms, and obtain further orders. The client is displaying symptoms that indicate potential complications, such as internal bleeding, which require immediate medical evaluation. Option A is incorrect because the client's condition suggests a more urgent need for assessment. Option C is inappropriate as it does not address the seriousness of the client's symptoms. Option D is dangerous and could exacerbate any underlying issue the client may be experiencing.
When a patient is prescribed an oral anticoagulant, what should the nurse monitor for?
- A. Elevated blood glucose
- B. Decreased blood pressure
- C. Signs of bleeding
- D. Increased appetite
Correct Answer: C
Rationale: When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants work by inhibiting the blood's ability to clot, which increases the risk of bleeding. Monitoring for signs of bleeding such as easy bruising, petechiae, hematuria, or bleeding gums is crucial to prevent complications. Elevated blood glucose (Choice A) is not directly related to oral anticoagulant use. Decreased blood pressure (Choice B) is not a common effect of oral anticoagulants. Increased appetite (Choice D) is not a typical side effect of oral anticoagulants and is not a primary concern when monitoring a patient on this medication.
A patient with hypothyroidism should be advised to consume more of which nutrient?
- A. Calcium
- B. Iodine
- C. Vitamin C
- D. Iron
Correct Answer: B
Rationale: The correct answer is B: Iodine. Iodine is essential for thyroid hormone production, and its deficiency can contribute to hypothyroidism. While calcium, vitamin C, and iron are important for overall health, they are not specifically related to thyroid function. Calcium is more associated with bone health, vitamin C with immune function, and iron with red blood cell production.
Which of the following grains is acceptable for someone with celiac disease?
- A. Rice
- B. Rye
- C. Wheat
- D. Barley
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?
- A. Discontinue the use of steroid therapy immediately if symptoms develop.
- B. Take diuretics as needed to treat the dependent edema in ankles.
- C. Increase the intake of dietary sodium every day to decrease fluid retention.
- D. Report any decrease in daily weight during treatment to the healthcare provider.
Correct Answer: D
Rationale: The correct intervention for the nurse to include in the care plan for a client diagnosed with nephritic syndrome is to instruct the client to report any decrease in daily weight during treatment to the healthcare provider. A decrease in weight could indicate worsening of the nephritic syndrome or dehydration, making it crucial information for the healthcare provider to assess the client's condition. Option A is incorrect because discontinuing steroid therapy should be done under medical guidance rather than immediately if symptoms develop. Option B is incorrect because diuretics should not be taken without healthcare provider's guidance due to the risk of electrolyte imbalances. Option C is incorrect as increasing dietary sodium would exacerbate fluid retention, which is undesirable in nephritic syndrome.