Nokea
Which dietary consideration is most important for the nurse to teach to a client with hypothyroidism?
- A. Increase carbohydrate intake
- B. Increase fluid intake
- C. Avoid shellfish
- D. Increase fiber
Correct Answer: D
Rationale: The correct answer is to 'Increase fiber.' In hypothyroidism, clients often experience constipation due to decreased metabolic rate. Increasing fiber in the diet can help alleviate constipation. Choice A, 'Increase carbohydrate intake,' is incorrect as there is no specific need to increase carbohydrate intake in hypothyroidism. Choice B, 'Increase fluid intake,' is not directly related to managing hypothyroidism, although adequate hydration is generally important for overall health. Choice C, 'Avoid shellfish,' is commonly associated with hyperthyroidism due to its iodine content, not hypothyroidism.
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The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hand
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the cased leg on two pillows
Correct Answer: B
Rationale: The correct answer is covering the affected leg with a blanket to avoid chills. Covering the leg with a blanket can prevent the evaporation of heat from the new cast, which can lead to skin irritation or discomfort. Lifting the affected leg with the palms of the hand is appropriate as it helps in providing support and prevents unnecessary pressure on the cast. Placing plastic over the groin prior to bathing is also acceptable to protect the area from getting wet. Elevating the cased leg on two pillows helps reduce swelling and promotes circulation, making it a suitable action.
A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that he lost consciousness for 1-2 minutes. On admission, the client's Glasgow Coma Scale (GCS) was 14. The GCS is now 12. The nurse should:
- A. Re-assess in 15 minutes
- B. Stimulate the client with a sternal rub
- C. Administer Tylenol with codeine for a headache
- D. Notify the physician
Correct Answer: D
Rationale: A decrease in the Glasgow Coma Scale (GCS) score from 14 to 12 indicates a significant neurological change in the client's condition. This change can be indicative of a deterioration in the client's neurological status, possibly due to intracranial bleeding or swelling. It is crucial for the nurse to notify the physician immediately to ensure prompt evaluation and intervention. Re-assessing in 15 minutes or stimulating the client with a sternal rub are not appropriate actions in this situation as they do not address the underlying cause of the decrease in GCS. Administering Tylenol with codeine for a headache is also not recommended without further assessment and evaluation of the client's condition.
Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?
- A. The hematocrit is adversely affected due to increased vascular volume.
- B. AEDs can lead to blood dyscrasia as a side effect.
- C. AEDs may cause aplastic anemia and megaloblastic anemia.
- D. Some AEDs induce white blood cell reduction.
Correct Answer: B
Rationale: When a client is being treated with antiepileptic drugs (AEDs), it is essential to monitor for potential side effects on blood parameters. Some AEDs can lead to blood dyscrasia, which includes conditions like aplastic anemia and megaloblastic anemia. Therefore, drawing a complete blood count and differential helps in identifying these adverse effects early. Choices A, C, and D are incorrect because the primary concern when monitoring blood parameters in clients on AEDs is the risk of blood dyscrasia, not changes in hematocrit due to vascular volume, white blood cell reduction, or immune modulation.
After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?
- A. Go to the client to assess for signs and symptoms of decreased cardiac output.
- B. Call the physician to inform them of the VF episode for medication adjustments.
- C. Call the 'on-call' person in the cath lab to re-charge the ICD in case of a recurrence.
- D. Document the incident on the code report form and follow up regularly.
Correct Answer: A
Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.
The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?
- A. Facial flushing
- B. A complaint of chest heaviness
- C. Heart rate increase of 10 beats/min
- D. Systolic blood pressure increase of 10 mm Hg
Correct Answer: B
Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.