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The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
- A. Grave's disease.
- B. Multiple sclerosis.
- C. Addison's disease.
- D. Cushing syndrome.
Correct Answer: A
Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism.
Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism.
Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones.
Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia.
Step 5: Therefore, the findings described in the question are consistent with Grave's disease.
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A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
- A. Blood transfusion
- B. Furosemide
- C. Dobutamine infusion
- D. Dopamine hydrochloride infusion
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion.
Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.
A PaCO 2 of 48 mm Hg is associated with what outcome?
- A. Hyperventilation
- B. Hypoventilation
- C. Increased absorption of O
- D. Increased excretion of HCO
Correct Answer: B
Rationale: The correct answer is B: Hypoventilation. A PaCO2 of 48 mm Hg indicates an elevated level of carbon dioxide in the blood, which is typically seen in hypoventilation where the lungs are not effectively removing CO2. Hypoventilation leads to respiratory acidosis. Option A is incorrect because hyperventilation would decrease PaCO2 levels. Option C is incorrect as it does not directly relate to PaCO2 levels. Option D is incorrect as increased excretion of HCO3- would not directly affect PaCO2 levels.
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
- A. Predict the likelihood of the outcome.
- B. Consider alternatives.
- C. Choose the most successful approach.
- D. Identify the problem.
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.
A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.
B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.
C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.
A patient in hospice care is experiencing dyspnea. What is the most appropriate nursing intervention?
- A. Position the patient flat on their back.
- B. Administer oxygen as prescribed.
- C. Restrict fluid intake to reduce congestion.
- D. Perform chest physiotherapy to improve breathing.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen as prescribed. Dyspnea in a hospice patient often indicates respiratory distress, and administering oxygen can help improve oxygenation and alleviate breathing difficulty. Positioning the patient flat on their back (A) may worsen dyspnea due to increased pressure on the diaphragm. Restricting fluid intake (C) is not appropriate as dehydration can exacerbate respiratory distress. Chest physiotherapy (D) may not be suitable for a hospice patient experiencing dyspnea as it can be physically taxing and may not address the underlying cause effectively.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?
- A. “I’m going to contact the pharmacist to see if you can take this medication by mouth.”
- B. “This injection is being given to prevent blood clots fr om forming.”
- C. “This medication will dissolve any blood clots you migabhirtb .gcoemt./”te st
- D. “I will contact your primary care provide to discuss wh y you are getting this medication.” t
Correct Answer: B
Rationale: The correct answer is B: “This injection is being given to prevent blood clots from forming.” Enoxaparin is an anticoagulant used to prevent blood clots. It is administered through injection, not orally (A). Enoxaparin does not dissolve existing blood clots (C). Contacting the primary care provider to discuss the medication is not necessary in this scenario (D). The correct choice emphasizes the purpose of enoxaparin in preventing new blood clots.