Nursing Elites

1. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?

• A. Increased TSH
• B. Increased thyroxine (T4)
• C. Decreased TSH
• D. Decreased T3

Correct answer: A

Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.

2. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?

• A. Social isolation related to hearing loss
• B. Risk for injury related to vertigo
• C. Impaired verbal communication
• D. Impaired hearing related to ear disease

Correct answer: B

Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.

3. A client is being prepared for surgery and has been placed on NPO status. Which of the following is the nurse's priority assessment?

• A. Assess the client's understanding of the procedure
• B. Monitor the client's compliance with NPO status
• C. Check the client's vital signs
• D. Ensure the client's consent form is signed

Correct answer: B

Rationale: The correct answer is B. Monitoring the client's compliance with NPO status is the priority assessment. Ensuring the client remains NPO (nothing by mouth) is crucial to reduce the risk of aspiration during surgery. Assessing the client's understanding of the procedure is important but not the priority at this moment. Checking vital signs is also essential but ensuring NPO status takes precedence for patient safety. Ensuring the client's consent form is signed is necessary but not the priority assessment compared to maintaining NPO status.

4. Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?

• A. Maintaining a low-sugar diet
• B. Foot care
• C. Blood glucose monitoring
• D. Daily exercise

Correct answer: C

Rationale: Blood glucose monitoring is crucial for managing diabetes effectively. By monitoring blood sugar levels, individuals can understand how their lifestyle choices, medications, and diet affect their glucose levels. This information helps in making necessary adjustments to control blood sugar levels and prevent complications. While maintaining a low-sugar diet, foot care, and daily exercise are all important aspects of managing diabetes, blood glucose monitoring takes precedence as it provides real-time data for informed decision-making.

5. A client with a history of type 2 diabetes is admitted with hyperglycemia. What is the nurse's priority action?

• A. Administer a dose of insulin as prescribed.
• B. Check the client's blood glucose level.
• C. Administer a fluid bolus to improve hydration.
• D. Monitor the client's intake and output closely.

Correct answer: B

Rationale: The correct answer is to check the client's blood glucose level. This is the priority action when dealing with a client admitted with hyperglycemia. Checking the blood glucose level helps determine the severity of hyperglycemia and guides further treatment. Administering insulin or fluids or monitoring intake and output are important interventions but should come after assessing the blood glucose level to inform the most appropriate course of action.

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