Nursing Elites

1. Which of the following is a key symptom of hypothyroidism?

• A. Weight loss.
• B. Heat intolerance.
• C. Cold intolerance.
• D. Increased appetite.

Correct answer: C

Rationale: Cold intolerance is a key symptom of hypothyroidism because a decreased metabolic rate leads to a reduced ability to regulate body temperature. Weight loss (Choice A) is more commonly associated with hyperthyroidism, where the metabolic rate is increased. Heat intolerance (Choice B) is also more indicative of hyperthyroidism, where excess thyroid hormone leads to an increased sensitivity to heat. Increased appetite (Choice D) is not typically seen in hypothyroidism; instead, individuals with hypothyroidism may experience weight gain due to the slowed metabolism.

2. A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?

• A. Explain the effects of follicle-stimulating and luteinizing hormones.
• B. Discuss perimenopause and related comfort measures.
• C. Assess lung fields and check for a cough productive of blood-tinged mucus.
• D. Inquire if a fever above 101°F (38.3°C) has occurred in the last 24 hours.

Correct answer: B

Rationale: The correct answer is B. The symptoms described by the client, excessive diaphoresis and feeling warm at night, are characteristic of perimenopause. During this period, lower estrogen levels lead to surges in follicle-stimulating hormone (FSH) and luteinizing hormone (LH), resulting in vasomotor instability, night sweats, and hot flashes. Therefore, discussing perimenopause and related comfort measures with the client is essential to provide education and support. Choice A is incorrect because explaining the effects of FSH and LH alone does not directly address the client's current symptoms. Choice C is irrelevant as it focuses on assessing lung fields and cough symptoms, which are not related to the client's menopausal symptoms. Choice D is not the best response as it is more focused on ruling out fever as a cause, which is not typically associated with the symptoms described by the client.

3. After a myocardial infarction, why is the hospitalized client taught to move the legs while resting in bed?

• A. Prepare the client for ambulation.
• B. Promote urinary and intestinal elimination.
• C. Prevent thrombophlebitis and blood clot formation.
• D. Decrease the likelihood of pressure ulcer formation.

Correct answer: C

Rationale: The correct answer is C. Moving the legs helps prevent thrombophlebitis and blood clot formation by promoting venous return in clients on bed rest. This prevents stasis and clot formation in the lower extremities. Choices A, B, and D are incorrect because the primary goal of moving the legs is to prevent thrombophlebitis and blood clot formation, rather than preparing for ambulation, promoting elimination, or decreasing pressure ulcer formation. Ambulation preparation involves different exercises, urinary and intestinal elimination are not directly related to leg movements, and pressure ulcer prevention is more related to repositioning and skin care.

4. After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP’s understanding. Which action indicates the UAP needs additional teaching?

• A. Toileting the client after breakfast
• B. Changing the client’s incontinence brief when wet
• C. Encouraging the client to drink fluids
• D. Recording the client’s incontinence episodes

Correct answer: B

Rationale: The correct action that indicates the UAP needs additional teaching is choice B, 'Changing the client’s incontinence brief when wet.' Habit training is a technique used to manage incontinence, and it is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training, which involves scheduled toileting and promoting bladder control. Choices A, C, and D are appropriate actions that support the client’s care: toileting the client after meals, encouraging fluid intake, and documenting incontinence episodes are all important aspects of managing incontinence and monitoring the client's condition.

5. The healthcare provider notes a blood pressure of 160/90 mm Hg in a patient taking a thiazide diuretic. The patient reports taking an herbal medication that a friend recommended. Which herbal product is likely, given this patient’s blood pressure?

• A. Ginkgo
• B. Hawthorn
• C. Licorice
• D. St. John’s wort

Correct answer: A

Rationale: The correct answer is A: Ginkgo. Increased blood pressure can result when ginkgo is used in combination with a thiazide diuretic. Option B (Hawthorn) is incorrect because hawthorn is more commonly associated with lowering blood pressure. Option C (Licorice) is incorrect because licorice can lead to sodium and water retention, potentially exacerbating hypertension. Option D (St. John’s wort) is incorrect as it is not typically associated with significant blood pressure effects.

Similar Questions