Nokea
Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm?
- A. Obstipation and hypoactive bowel sounds.
- B. Hyperpyrexia and extreme tachycardia.
- C. Hypotension and bradycardia.
- D. Decreased respirations and hypoxia.
Correct Answer: B
Rationale: Thyroid storm causes hyperpyrexia (high fever) and extreme tachycardia due to excessive thyroid hormone. Other options are hypothyroid or unrelated.
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Which statement by the client indicates a misunderstanding of the expected surgical outcome?
- A. My appearance will gradually become normal.
- B. I'll need to take replacement hormones.
- C. I'll need to see my physician regularly.
- D. The surgical incision will be inconspicuous.
Correct Answer: A
Rationale: In acromegaly, physical changes such as enlarged hands or facial features are typically irreversible, even after surgery.
At 10 A.M., a client with Type 1 diabetes becomes very irritable and starts to yell at the nurse. Which initial nursing assessment should take priority?
- A. Blood pressure and pulse
- B. Color and temperature of skin
- C. Reflexes and muscle tone
- D. Serum electrolytes and glucose
Correct Answer: D
Rationale: Irritability in Type 1 diabetes suggests hypoglycemia or hyperglycemia, requiring priority assessment of serum glucose.
The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership?
- A. Call a meeting and educate the staff on the new delivery system being used.
- B. Organize a committee to investigate the various types of delivery systems.
- C. Wait until another unit has implemented the new system and see if it works out.
- D. Discuss with the nursing staff if a new delivery system should be adopted.
Correct Answer: A
Rationale: An autocratic leader unilaterally decides and informs staff, as in educating them on a chosen system. Committees, waiting, and staff discussions are democratic or laissez-faire.
The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement?
- A. Instruct the UAP to get the client additional food.
- B. Notify the dietitian about the client's request.
- C. Request the HCP increase the client's caloric intake.
- D. Tell the UAP the client cannot have anything else.
Correct Answer: B
Rationale: Notifying the dietitian ensures the client’s nutritional needs are met within DKA dietary restrictions. Additional food, caloric increases, or denial are inappropriate without consultation.
Which characteristic findings would the nurse expect to assess in a client with Addison's disease? Select all that apply.
- A. Salt craving
- B. Skin blemishes
- C. Moon-shaped face
- D. Bronzed skin
- E. Hypoglycemia
- F. Weight loss
Correct Answer: A,D,E,F
Rationale: Addison's disease causes adrenal insufficiency, leading to salt craving, bronzed skin, hypoglycemia, and weight loss.