Nokea
A client with hyperthyroidism.
Which of the following actions, if taken by the nurse, is BEST?
- A. Provide the client with extra blankets.
- B. Instill artificial tears prn.
- C. Offer the client reading material.
- D. Offer frequent low-calorie snacks.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is usually sensitive to heat (2) correct-clients with hyperthyroidism frequently exhibit exophthalmos, which requires ophthalmic drops on a regular basis (3) should provide a calm, restful environment with low levels of sensory stimulation, protecting eyes from injury takes priority (4) frequent snacks should be high-calorie
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A 34-year-old multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore.
Which of the following suggestions by the nurse is BEST?
- A. Apply warm compresses to your breasts and take two aspirin as needed.
- B. Massage your breasts with lotion and wear loose-fitting clothing.
- C. Apply cold compresses to your breasts and wear a well-fitting, supportive bra.
- D. Take a diuretic once a day and avoid touching your breasts.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort, should avoid taking medications (2) not effective in decreasing discomfort (3) correct-during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue (4) medications are to be avoided during pregnancy
The nurse is teaching a client with a new diagnosis of chronic kidney disease about sevelamer (Renagel). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I should report constipation to my doctor.
- C. I should avoid taking this with my calcium supplement.
- D. I should stop this medication if my phosphate levels are normal.
Correct Answer: D
Rationale: Stopping sevelamer when phosphate levels are normal is incorrect, as chronic kidney disease requires ongoing phosphate control to prevent complications. Options A, B, and C are correct: taking with meals binds phosphate, constipation is a side effect, and calcium supplements interfere with absorption.
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
- A. Increased retention of albumin in the vascular system
- B. Decreased colloidal osmotic pressure in the capillaries
- C. Fluid shift from interstitial spaces into the vascular space
- D. Reduced tubular reabsorption of sodium and water
Correct Answer: B
Rationale: Decreased colloidal osmotic pressure in the capillaries. Loss of albumin reduces osmotic pressure, causing edema.
Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct Answer: A
Rationale: Liver function. INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.
A woman who recently had a simple mastectomy is about to be discharged. She seems very concerned about such things as where to find the best prosthesis, suitable underwear, and swimsuits, and adjusting to life with only one breast. Which resource is appropriate for the nurse to recommend?
- A. A psychologist or psychiatrist
- B. Reach to Recovery
- C. Pastoral counseling
- D. Her physician
Correct Answer: B
Rationale: Reach to Recovery offers peer support and resources for mastectomy patients, addressing prosthesis and lifestyle adjustments. Other options are less specific.