Nokea
Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?
- A. Cold sensitivity.
- B. Hot flashes.
- C. Weight gain.
- D. Dry skin.
Correct Answer: A
Rationale: The correct answer is A: Cold sensitivity. Cold sensitivity is a common symptom of hypothyroidism, a condition that affects the thyroid gland's ability to produce enough hormones. As a postmenopausal woman presents with cold sensitivity, it may indicate an underlying thyroid issue. Hot flashes (choice B) are more commonly associated with menopause than thyroid dysfunction. While weight gain (choice C) and dry skin (choice D) can also be symptoms of thyroid disorders, cold sensitivity is more specific and indicative of hypothyroidism, requiring prompt evaluation by a healthcare provider.
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The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse?
- A. Serum creatinine of 4.5 mg/dL (398 μmol/L SI)
- B. Temperature of 101.3°F
- C. Blood pressure of 140/90 mmHg
- D. Heart rate of 88 bpm
Correct Answer: A
Rationale: A serum creatinine level of 4.5 mg/dL indicates severe renal impairment, which requires immediate attention before administering ciprofloxacin. Elevated serum creatinine levels suggest decreased kidney function, and giving ciprofloxacin can further harm the kidneys. Monitoring and addressing renal function are crucial to prevent worsening of renal impairment and potential drug toxicity. The temperature, blood pressure, and heart rate are important parameters to assess, but in this scenario, the priority is to address the severe renal impairment before proceeding with ciprofloxacin administration.
In a client with cirrhosis admitted with jaundice and ascites, which laboratory value is most concerning?
- A. Serum bilirubin of 3.0 mg/dl
- B. Serum albumin of 3.0 g/dl
- C. Serum ammonia level of 80 mcg/dl
- D. Serum sodium level of 135 mEq/L
Correct Answer: C
Rationale: A serum ammonia level of 80 mcg/dl is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. Elevated ammonia levels are associated with impaired liver function and can lead to mental status changes. Serum bilirubin (Choice A) is elevated in cirrhosis but not as concerning for acute intervention as high ammonia levels. Serum albumin (Choice B) and serum sodium (Choice D) levels are important in cirrhotic patients but are not as directly associated with hepatic encephalopathy as ammonia levels.
A male client is prescribed clozapine (Clozaril), an antipsychotic medication, for the management of schizophrenia. Which client history should the nurse report to the healthcare provider before administering the first dose of this medication?
- A. History of depression
- B. History of cardiac arrhythmia
- C. History of seizures
- D. History of diabetes mellitus
Correct Answer: B
Rationale: The correct answer is B: History of cardiac arrhythmia. Clozapine can lead to severe cardiovascular problems, making it crucial to report any history of cardiac arrhythmia to the healthcare provider before administering the medication. Choices A, C, and D are less concerning in this context as they are not directly associated with potential serious complications related to clozapine use.
A client with a history of congestive heart failure is admitted with shortness of breath. Which nursing intervention should the nurse implement first?
- A. Elevate the head of the bed.
- B. Administer prescribed diuretic therapy.
- C. Monitor the client's oxygen saturation.
- D. Assess the client's level of consciousness.
Correct Answer: A
Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed is crucial in improving oxygenation in clients with congestive heart failure and shortness of breath by reducing venous return to the heart and decreasing fluid overload in the lungs. This intervention helps to alleviate the client's breathing difficulty. Administering diuretic therapy (Choice B) may be necessary but is not the initial priority. Monitoring oxygen saturation (Choice C) is important but should come after ensuring proper positioning. Assessing the client's level of consciousness (Choice D) is essential but is not the first intervention needed for a client experiencing respiratory distress.
A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?
- A. Monitor for signs of alcohol withdrawal.
- B. Administer thiamine as prescribed.
- C. Provide a quiet environment to reduce confusion.
- D. Initiate fall precautions.
Correct Answer: B
Rationale: The correct answer is to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.