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When caring for a client, whose being treated for hyperthyroidism, it’s important to:
- A. Provide extra blankets and clothing to keep the client warm.
- B. Monitor the client for signs of restlessness, sweating and excessive weight loss during thyroid replacement therapy.
- C. Balance the client’s periods of activity and rest.
- D. Encourage the client to be active to prevent constipation.
Correct Answer: B
Rationale: The correct answer is B. Monitoring for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy is essential in managing hyperthyroidism. Restlessness can indicate increased metabolic rate, sweating can be due to excessive heat production, and weight loss can be a sign of overactive thyroid function. Providing extra blankets (Choice A) may worsen symptoms of heat intolerance. Balancing activity and rest (Choice C) is important, but not specific to hyperthyroidism. Encouraging activity to prevent constipation (Choice D) is not directly related to managing hyperthyroidism.
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Cancer is the second major cause of death in this country. What is the first step toward effective cancer control?
- A. Increasing governmental control of potential carcinogens
- B. Changing habits and customs that predispose the individual to cancer
- C. Conducting more mass screening programs
- D. Educating public and professional people about cancer
Correct Answer: B
Rationale: The correct answer is B because changing habits and customs that predispose the individual to cancer is crucial in preventing cancer. This includes lifestyle changes such as quitting smoking, maintaining a healthy diet, exercising regularly, and avoiding excessive sun exposure. By modifying behaviors that increase cancer risk, individuals can significantly reduce their chances of developing cancer.
A: Increasing governmental control of potential carcinogens is not the first step towards effective cancer control as individual behaviors have a more direct impact on cancer risk.
C: Conducting more mass screening programs is important but not the first step as prevention through lifestyle changes takes priority.
D: Educating the public and professionals about cancer is essential but changing habits is the initial crucial step in effective cancer control.
If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
- A. Flexion of both upper and lower extremities
- B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
- C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
- D. Extension of upper extremities, flexion of lower extremities
Correct Answer: B
Rationale: The correct answer is B because decorticate posturing is characterized by the flexion of elbows, wrists, and fingers, extension of elbows and knees, plantar flexion of feet. This pattern indicates damage to the cerebral hemispheres or internal structures of the brain. In contrast, option A describes decerebrate posturing, which indicates more severe brain damage. Option C is incorrect as it describes a mixed pattern of posturing. Option D is also incorrect as it describes a different type of posturing called decerebrate posturing.
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
- A. Posttrauma syndrome
- B. Constipation
- C. Acute pain
- D. Anxiety
Correct Answer: C
Rationale: The correct answer is C: Acute pain. This is the most pertinent nursing diagnosis because the patient has a right femur fracture and reports moderate discomfort. The priority is to address the acute pain associated with the fracture. Posttrauma syndrome (A) typically involves a broader range of emotional and psychological responses beyond just moderate discomfort. Constipation (B) is not the priority in this case, as it is not directly related to the patient's current condition. Anxiety (D) may be present but addressing the acute pain takes precedence in this situation to ensure the patient's comfort and well-being.
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
- A. Unequal growth of fingers and toes.
- B. Purplish discoloration of hands and feet.
- C. Webbing between fingers and toes.
- D. Deformities of the wrists and ankles.
Correct Answer: B
Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.
Bell’s palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
- A. 3rd
- B. 7th
- C. 5th
- D. 8th
Correct Answer: B
Rationale: The correct answer is B: 7th cranial nerve. Bell's palsy is caused by inflammation of the facial nerve (7th cranial nerve), leading to facial muscle weakness or paralysis. The 3rd cranial nerve (choice A) controls eye movement, the 5th cranial nerve (choice C) is responsible for facial sensation and chewing, and the 8th cranial nerve (choice D) is related to hearing and balance. Bell's palsy specifically affects the facial muscles, making choice B the correct answer.