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. Which of the following laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto’s thyroiditis?
- A. Thyroxine (T4), 22 ug/dl; triiodothyronine (T3), 320ng/dl; thyroid-stimulating hormone
- B. (TSH) undetectable
- C. T4, 22 ug/dl; T3, 200 ng/dl; TSH 0.1 uIU/ml
- D. T4, 2 ug/dl; t3, 35 ng/dl; TSH 45 uIU/ml
Correct Answer: C
Rationale: Rationale for correct answer C: In Hashimoto's thyroiditis, an autoimmune disorder causing hypothyroidism, we expect to see normal to elevated TSH levels due to the pituitary gland stimulating the thyroid to produce more hormones. T4 and T3 levels may be within normal range or slightly decreased. Choice C reflects this pattern with T4 at 22 ug/dl, T3 at 200 ng/dl, and TSH at 0.1 uIU/ml.
Summary of why other choices are incorrect:
- Choice A: T4 and T3 levels are higher than expected in Hashimoto's thyroiditis, and TSH should be elevated, not stated as normal.
- Choice B: An undetectable TSH level is typically seen in hyperthyroidism, not hypothyroidism like Hashimoto's.
- Choice D: T4 and T3 levels are significantly lower than expected, and TSH is much higher than typically seen in Hashimoto's
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A client is hospitalized with oat cell carcinoma of the lung. To manage severe pain, the physician prescribes a continuous I.V. infusion of morphine. Which formula should the nurse use to check that the morphine dose is appropriate for the client?
- A. 1 mg/kg of body weight
- B. 5 mg/70kg of body weight
- C. 5 mg/kg of body weight
- D. 10mg/70kg of body weight
Correct Answer: C
Rationale: The correct formula to calculate the appropriate morphine dose for the client is 5 mg/kg of body weight. This is the most suitable formula because morphine dosing is typically based on weight to ensure appropriate pain management and to prevent adverse effects. By using this formula, the nurse can calculate the exact dose based on the client's weight, providing personalized care.
Choice A (1 mg/kg of body weight) is too low of a dose and may not effectively manage severe pain. Choice B (5 mg/70kg of body weight) is not ideal as it does not account for variations in weight among individuals. Choice D (10mg/70kg of body weight) would result in an overdose for most patients, potentially causing serious harm.
Therefore, by using the formula of 5 mg/kg of body weight, the nurse can ensure that the morphine dose is appropriate and safe for the client.
A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?
- A. I have assessed you and find you are fatigued.
- B. I analyzed and interpreted your information as fatigue.
- C. Why are you so tired all the time?
- D. I think fatigue is a problem for you. Do you agree?
Correct Answer: D
Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. The nurse made an error in the assessment phase by not communicating the patient's condition promptly. Assessment involves collecting data and recognizing changes in the patient's condition. By not informing the nurse about feeling dizzy and light-headed, the nurse missed crucial information that could have indicated a deteriorating condition. The other choices are incorrect because: B: Diagnosis comes after assessment and involves analyzing data to identify the patient's problems. C: Implementation is the phase where nursing interventions are carried out based on the diagnosis. D: Evaluation is the final phase where the nurse assesses the effectiveness of interventions and outcomes.
Which of the ff is a sign or symptom of asthma?
- A. Production of abnormally thick, sticky mucus in lungs
- B. Faulty transport of sodium in lung cells
- C. Paroxysms or shortness of breath
- D. Altered electrolyte balance in the sweat glands
Correct Answer: C
Rationale: The correct answer is C: Paroxysms or shortness of breath. Asthma is characterized by episodes of wheezing, coughing, chest tightness, and shortness of breath, known as paroxysms. This symptom is caused by inflammation and constriction of the airways in response to triggers such as allergens or irritants.
A: Production of abnormally thick, sticky mucus in lungs is more indicative of conditions like cystic fibrosis, not asthma.
B: Faulty transport of sodium in lung cells is associated with conditions like cystic fibrosis, not asthma.
D: Altered electrolyte balance in the sweat glands is a symptom of cystic fibrosis, not asthma.
In summary, paroxysms or shortness of breath is a key sign of asthma due to airway inflammation and constriction, distinguishing it from the other choices that are more indicative of cystic fibrosis.
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.