Nursing Elites

1. An outcome for treatment of peripheral vascular disease is, 'The client will have decreased venous congestion.' What client behavior would indicate to the nurse that this outcome has been met?

• A. Avoids prolonged sitting or standing.
• B. Avoids trauma and irritation to skin.
• C. Wears protective shoes.
• D. Quits smoking.

Correct answer: A

Rationale: The correct answer is A: 'Avoids prolonged sitting or standing.' In clients with peripheral vascular disease, decreased venous congestion is a desired outcome. Avoiding prolonged sitting or standing helps improve venous return and reduces congestion in the lower extremities, contributing to the achievement of this treatment goal.

2. The healthcare provider is caring for a client who has just undergone a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarse voice.
• B. Difficulty swallowing.
• C. Numbness and tingling around the mouth.
• D. Sore throat.

Correct answer: C

Rationale: Numbness and tingling around the mouth can indicate hypocalcemia, a potential complication after thyroidectomy. Hypocalcemia can occur due to inadvertent injury or removal of the parathyroid glands during the thyroidectomy, leading to decreased calcium levels. As a result, the client may experience symptoms such as numbness, tingling, muscle cramps, or spasms. Prompt intervention is necessary to prevent severe complications like tetany or seizures. Therefore, the healthcare provider should address numbness and tingling around the mouth immediately to prevent further deterioration of calcium levels and potential serious outcomes. Choices A, B, and D are not typically associated with immediate post-thyroidectomy complications and can be addressed after ensuring the client's calcium levels are stable.

3. A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?

• A. Administer morphine sulfate.
• B. Place the client in a high Fowler's position.
• C. Initiate continuous ECG monitoring.
• D. Prepare the client for intubation.

Correct answer: B

Rationale: In a client with chronic heart failure experiencing severe shortness of breath and pink, frothy sputum, the priority action for the nurse is to place the client in a high Fowler's position. This position helps improve lung expansion, ease breathing, and enhance oxygenation by reducing venous return and decreasing preload on the heart. It is crucial to address the client's respiratory distress promptly before considering other interventions. Administering morphine sulfate (choice A) may be appropriate later to relieve anxiety and reduce the work of breathing, but positioning is the priority. Continuous ECG monitoring (choice C) and preparing for intubation (choice D) are important but secondary to addressing the respiratory distress and optimizing oxygenation.

4. A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What is the primary purpose of this medication?

• A. Increase thyroid hormone production
• B. Suppress thyroid hormone production
• C. Enhance iodine absorption
• D. Stimulate the thyroid gland

Correct answer: B

Rationale: Propylthiouracil (PTU) is a medication used to treat hyperthyroidism by suppressing the production of thyroid hormones. It works by inhibiting the enzyme responsible for the synthesis of thyroid hormones, thereby reducing their levels in the body. This helps to alleviate the symptoms of hyperthyroidism and restore thyroid hormone levels to normal range.

5. A 35-year-old woman presents with fatigue, weight gain, and cold intolerance. Laboratory tests reveal high TSH and low free T4 levels. What is the most likely diagnosis?

• A. Hypothyroidism
• B. Hyperthyroidism
• C. Thyroiditis
• D. Thyroid cancer

Correct answer: A

Rationale: The scenario describes a 35-year-old woman with symptoms of fatigue, weight gain, and cold intolerance along with high TSH and low free T4 levels. These findings are consistent with the diagnosis of hypothyroidism. In hypothyroidism, there is decreased thyroid hormone production leading to elevated TSH levels as the body tries to stimulate the thyroid to produce more hormone. The low free T4 levels indicate insufficient thyroid hormone in the blood, which can manifest as symptoms such as fatigue, weight gain, and cold intolerance.

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