When caring for a female client who is being treated for hyperthyroidism, it is important to:
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Solution
Balance the client’s periods of activity and rest.
Option C: A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm.
Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:
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Solution
Changes from previous examinations.
Option C: Women are instructed to examine themselves to discover changes that have occurred in the breast.
Options A, B, and D: Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.
Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:
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Solution
Bone fracture
Option A: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increased the fragility of bones.
Option B: Estrogen deficiencies result from menopause and not osteoporosis.
Option C: Calcium and vitamin D supplements may be used to support normal bone metabolism, But a negative calcium balance isn’t a complication of osteoporosis.
Option D: Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.
Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:
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Solution
Clipping the hair in the area
Option C: Hair can be a source of infection and should be removed by clipping.
Option B: Shaving the area can cause skin abrasions and depilatories can irritate the skin.
Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:
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Solution
Avoid foods high in vitamin K
Option B: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation.
Option A: The client may need to report diarrhea but isn’t effect of taking an anticoagulant.
Option C: An electric razor-not a straight razor-should be used to prevent cuts that cause bleeding.
Option D: Aspirin may increase the risk of bleeding; acetaminophen should be used for pain relief.
Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?
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Solution
Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
Option C: Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor.
Options A, B, and D: SaO2, blood pressure, and ICP are important factors but aren’t as significant as PVCs in the situation.
A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?
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Solution
Decreased vital capacity
Option D: Reduction in vital capacity is a normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in residual volume.
Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?
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Solution
Respiratory arrest
Option B: Narcotics can cause respiratory arrest if given in large quantities.
Options A, C, and D: It’s unlikely the client will have asthma attack or a seizure or wake up on his own.
Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?
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Solution
Acute asthma
Option A: Based on the client’s history and symptoms, acute asthma is the most likely diagnosis.
Options B, C, and D: He’s unlikely to have bronchial pneumonia without a productive cough and fever and he’s too young to have developed (COPD) and emphysema.
A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited?
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Solution
Chills, fever, night sweats, and hemoptysis
Option B: Typical signs and symptoms are chills, fever, night sweats, and hemoptysis.
Option A: Chest pain may be present from coughing but isn’t usual.
Option C: Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C).
Option D: Nausea, headache, and photophobia aren’t usual TB symptoms.