Nokea
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
- A. Polyuria, nausea, and severe headaches
- B. Polydipsia, translucent skin, and obesity
- C. Fever, tachycardia, and systolic hypertension
- D. Profuse diaphoresis, flushing, and constipation
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
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A client with a hip fracture is scheduled for surgery. Which preoperative teaching should the nurse include?
- A. Avoid coughing post-surgery
- B. Expect to ambulate immediately
- C. Use of incentive spirometry
- D. Limit fluid intake
Correct Answer: C
Rationale: Incentive spirometry prevents postoperative pulmonary complications like atelectasis, critical for a client with limited mobility post-hip surgery.
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
- A. Increased alertness.
- B. Circulatory collapse.
- C. Hypertension.
- D. Diuresis.
Correct Answer: B
Rationale: Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.
A client with a history of type 2 diabetes is prescribed exenatide (Byetta). The nurse should instruct the client to:
- A. Take the medication before meals.
- B. Monitor for signs of hypoglycemia.
- C. Take the medication at bedtime.
- D. Stop the medication if weight loss occurs.
Correct Answer: A, B
Rationale: Exenatide is taken before meals to control postprandial glucose, and hypoglycemia is a risk.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:
- A. If I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: D
Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.
While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
- A. Intrauterine infection.
- B. Fetal meconium staining.
- C. Erythroblastosis fetalis.
- D. Normal amniotic fluid.
Correct Answer: B
Rationale: Cloudy, thick amniotic fluid often indicates meconium staining, suggesting fetal distress, which requires further evaluation.