Nursing Elites

1. During the physical examination, Nurse Noah expects to assess which sign in a female client with a serum calcium level of 7.2 mg/dl?

• A. Trousseau's sign
• B. Homans' sign
• C. Hegar's sign
• D. Goodell's sign

Correct answer: A

Rationale: Trousseau's sign is a clinical indicator of hypocalcemia, characterized by carpal spasm when a blood pressure cuff is inflated above systolic pressure and maintained for a few minutes. This occurs due to increased neuromuscular irritability associated with low serum calcium levels. Homans' sign is used to assess for deep vein thrombosis and involves calf pain upon dorsiflexion of the foot. Hegar's sign is a softening of the lower uterine segment seen in pregnancy, while Goodell's sign is softening of the cervix also seen in pregnancy. Therefore, in this scenario, the correct assessment related to hypocalcemia would be Trousseau's sign.

2. Nurse Ruth is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

• A. Tetany
• B. Hemorrhage
• C. Thyroid storm
• D. Laryngeal nerve damage

Correct answer: A

Rationale: The correct answer is 'Tetany.' Tetany is characterized by muscle twitching, tingling, and numbness, which are indicative of hypocalcemia. After a thyroidectomy, accidental removal or damage to the parathyroid glands can lead to decreased calcium levels, resulting in tetany. Choice B, 'Hemorrhage,' is incorrect as it typically presents with symptoms such as sudden swelling, increased pain, or drop in blood pressure. Choice C, 'Thyroid storm,' is incorrect as it involves a sudden exacerbation of hyperthyroidism, leading to symptoms like fever, tachycardia, and confusion. Choice D, 'Laryngeal nerve damage,' is incorrect as it would manifest with voice changes, difficulty swallowing, or respiratory distress, not the symptoms described in the scenario.

3. Which of the following clinical findings would be most concerning in a client with hypothyroidism?

• A. Bradycardia
• B. Dry skin
• C. Constipation
• D. Depression

Correct answer: A

Rationale: Bradycardia in a client with hypothyroidism is the most concerning finding as it may indicate severe hypothyroidism, leading to decreased heart rate. Bradycardia can be a sign of myxedema coma, a life-threatening condition that requires immediate medical attention. Dry skin, constipation, and depression are common symptoms associated with hypothyroidism but are not as acutely concerning as bradycardia.

4. Capillary glucose monitoring is being performed every 4 hours for a female client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which she receives 8 U of regular insulin. Nurse Vince should expect the dose's:

• A. Onset to be at 2 p.m. and its peak to be at 3 p.m.
• B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
• C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
• D. Onset to be at 4 p.m. and its peak to be at 6 p.m.

Correct answer: C

Rationale: The correct answer is C. Regular insulin typically has an onset of action within 30 minutes and peaks 2-4 hours after administration. Given that the insulin was administered at 2 p.m., the onset of action can be expected around 2:30 p.m., and the peak effect would occur between 4-6 p.m. Choice A is incorrect as the onset and peak are too close together for regular insulin. Choice B is incorrect because the onset time is too soon after administration. Choice D is incorrect as the onset time is too delayed for regular insulin.

5. When instructing the female client diagnosed with hyperparathyroidism about diet, Nurse Gina should stress the importance of which of the following?

• A. Restricting fluids
• B. Restricting sodium
• C. Forcing fluids
• D. Restricting potassium

Correct answer: C

Rationale: The correct answer is C: Forcing fluids. Nurse Gina should stress the importance of forcing fluids to help prevent kidney stones and hypercalcemia in clients with hyperparathyroidism. Restricting fluids (choice A) is not recommended as dehydration can worsen the condition. Restricting sodium (choice B) is not directly related to the management of hyperparathyroidism. Restricting potassium (choice D) is not typically necessary in hyperparathyroidism unless hyperkalemia is present.

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