Nursing Elites

1. Which nursing diagnosis takes the highest priority for a female client with hyperthyroidism?

• A. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess
• B. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing
• C. Body image disturbance related to weight gain and edema
• D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

Correct answer: D

Rationale: The correct answer is D: Imbalanced nutrition: Less than body requirements related to thyroid hormone excess. In hyperthyroidism, increased metabolic rate leads to increased nutritional needs, causing weight loss and muscle wasting. Therefore, addressing imbalanced nutrition due to excessive thyroid hormone is a priority. Choice A is incorrect as hyperthyroidism typically leads to weight loss, not weight gain. Choice B is less of a priority as skin issues are secondary to the metabolic disturbances caused by hyperthyroidism. Choice C, body image disturbance, is important but addressing the client's nutritional needs should take precedence to prevent further complications.

2. The nurse is caring for a client with primary adrenal insufficiency (Addison's disease). Which of the following laboratory findings would the nurse expect?

• A. Hypernatremia
• B. Hyperkalemia
• C. Hyperglycemia
• D. Hypercalcemia

Correct answer: B

Rationale: In primary adrenal insufficiency (Addison's disease), there is a decrease in aldosterone levels, leading to sodium loss and potassium retention. This imbalance results in hyperkalemia, making choice B the correct answer. Hypernatremia (choice A) is unlikely due to sodium loss. Hyperglycemia (choice C) and hypercalcemia (choice D) are not typically associated with primary adrenal insufficiency.

3. A client with DM is experiencing symptoms of hypoglycemia. Which action should the nurse take first?

• A. Give the client a glass of orange juice.
• B. Administer insulin as ordered.
• C. Check the client's blood glucose level.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: The correct first action when a client with DM is experiencing symptoms of hypoglycemia is to check the client's blood glucose level. This step is crucial to confirm hypoglycemia before initiating any treatment. Giving the client orange juice (Choice A) is a common intervention for treating hypoglycemia, but it should not be done before confirming the blood glucose level. Administering insulin (Choice B) is not appropriate for hypoglycemia as it would further decrease the blood glucose levels. Notifying the healthcare provider (Choice D) can be important, but the immediate priority is to assess the blood glucose level to guide treatment.

4. Which of the following ethical principles is involved when protecting a patient's privacy and confidentiality?

• A. Fidelity
• B. Beneficence
• C. Confidentiality
• D. Justice

Correct answer: C

Rationale: Confidentiality is the ethical principle involved in protecting a patient's privacy and ensuring that personal information is not shared inappropriately. Fidelity refers to being faithful to commitments and keeping promises, not directly related to privacy and confidentiality. Beneficence involves doing good for the patient, and justice pertains to fairness and equal treatment, but they are not directly related to protecting privacy and confidentiality.

5. A client with hyperthyroidism is prescribed methimazole. The nurse should instruct the client that the purpose of this medication is to:

• A. Decrease thyroid hormone production
• B. Increase thyroid hormone production
• C. Suppress the immune system
• D. Prevent thyroid storm

Correct answer: A

Rationale: The correct answer is A: Decrease thyroid hormone production. Methimazole works by inhibiting the synthesis of thyroid hormones, specifically by blocking the enzyme responsible for this process. By reducing the production of thyroid hormones, methimazole helps to normalize the elevated levels seen in hyperthyroidism. Choices B, C, and D are incorrect. Choice B, 'Increase thyroid hormone production,' is inaccurate as methimazole actually decreases thyroid hormone production. Choice C, 'Suppress the immune system,' is unrelated to the mechanism of action of methimazole. Choice D, 'Prevent thyroid storm,' is not the primary purpose of methimazole; while it may help prevent worsening of hyperthyroidism, its main action is to reduce thyroid hormone levels.

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