Nursing Elites

1. Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?

• A. Cold sensitivity.
• B. Hot flashes.
• C. Weight gain.
• D. Dry skin.

Correct answer: A

Rationale: The correct answer is A: Cold sensitivity. Cold sensitivity is a common symptom of hypothyroidism, a condition that affects the thyroid gland's ability to produce enough hormones. As a postmenopausal woman presents with cold sensitivity, it may indicate an underlying thyroid issue. Hot flashes (choice B) are more commonly associated with menopause than thyroid dysfunction. While weight gain (choice C) and dry skin (choice D) can also be symptoms of thyroid disorders, cold sensitivity is more specific and indicative of hypothyroidism, requiring prompt evaluation by a healthcare provider.

2. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

• A. Elevated blood pressure must be anticipated and identified quickly
• B. Frequent monitoring helps ensure the medication is effective
• C. It is standard protocol for all hospitalized children
• D. We need to monitor for any potential kidney damage

Correct answer: A

Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.

3. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?

• A. Serum potassium of 3.0 mEq/L
• B. Serum glucose of 200 mg/dl
• C. Serum pH of 7.30
• D. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention. Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (Choice A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (Choice B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (Choice D) is within the normal range and not the immediate priority.

4. A client with a tracheostomy is experiencing thick, tenacious secretions. Which intervention should the nurse implement first?

• A. Encourage fluid intake to thin secretions.
• B. Administer a mucolytic agent.
• C. Increase humidity in the client's room.
• D. Perform deep suctioning as needed.

Correct answer: C

Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.

5. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Increased abdominal girth

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

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