88 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5261) 

What is the nursing priority when administering care to a client with severe hyperthyroidism? 

A. Assess for recent emotional trauma 

B. Provide a calm, nonstimulating environment. 

C. Provide diversionary activity. 

D. Encourage range-of-motion exercises. 

Answer: B 

Explanation: A calm environment is important to reduce activity. Hyperthyroidism makes a person hyperactive and easily distractible. There is no reason to assess for emotional trauma. The hyperthyroid client is usually hyperactive, so there would be no need for range-of-motion exercises. 

Question 5262) 

Which problem is most likely to develop if hyperthyroidism remains untreated? 

A. Pulmonary embolism 

B. Respiratory acidosis 

C. Cerebro vascular accident 

D. Heart failure 

Answer: D 

Explanation: Hyperthyroidism causes tachycardia, which can be severe enough to cause heart failure. Pulse rates can be 100 to 150 per minute. 

Question 5263) 

Which nursing care measure is essential because a client has exophthalmos? 

A. Administer artificial tears 

B. Encourage the client to wear her glasses. 

C. Promote bed rest. 

D. Monitor her pulse rate every four hours. 

Answer: A 

Explanation: Exophthalmos (protrusion of the eyes) may be so severe that the eyelids cannot close. Artificial tears will keep the eyes moist so that abrasions do not occur. The client who has exophthalmos may or may not have glasses. Bed rest and monitoring pulse rate may be appropriate for a client who has exophthalmos because exophthalmos occurs in persons who are hyperthyroid. However, the question asks what nursing care is essential because the client has exophthalmos. 

Question 5264) 

A client who has just had a thyroidectomy returns to the unit in stable condition. What equipment is it essential for the nurse to have readily available? 

A. Tracheostomy set 

B. Thoracotomy tray 

C. Dressing set 

D. Ice collar 

Answer: A 

Explanation: Swelling in the operative site could cause airway obstruction. The nurse should have a tracheostomy set and oxygen readily available for 48 hours after thyroidectomy. A thoracotomy tray is not indicated. This client is not likely to need intervention in the thoracic cavity. A dressing set is unlikely to be needed in the immediate postoperative period. An ice collar might be indicated but is not critical to have at the bedside. 

Question 5265) 

What is the best way to assess for hemorrhage in a client who has had a thyroidectomy? 

A. Check the pulse and blood pressure hourly. 

B. Roll the client to the side and check for evidence of bleeding. 

C. Ask the client if he/she feels blood trickling down the back of the throat. 

D. Place a hand under the client’s neck and shoulders to feel bed linens. 

Answer: D 

Explanation: Following a thyroidectomy, the client is in semi-sitting position so drainage would go to the back of the neck. Because of the neck incision, the client should not be rolled to the side. The bleeding is unlikely to be inside the throat. Blood trickling down the throat might be seen in a client who has had a tonsillectomy. 

Question 5266) 

Which finding would be the greatest cause for concern to the nurse during the early postoperative period following a thyroidectomy? 

A. Temperature of 100°F 

B. A sore throat 

C. Carpal spasm when the blood pressure is taken 

D. Complaints of pain in the area of the surgical incision 

Answer: C 

Explanation: Carpal spasm is a sign of tetany and is known as Chvostek’s sign. Tetany may occur if the parathyroids have been inadvertently removed or damaged. The parathyroids regulate calcium phosphorus balance. Hypocalcemia causes tetany. Most clients who have been intubated during surgery have a sore throat. Pain in the incision area is normal in the immediate postoperative period. 

Question 5267) 

An adult is admitted to the hospital with a diagnosis of hypothyroidism. Which findings would the nurse most likely elicit during the nursing assessment? 

A. Elevated blood pressure and temperature 

B. Tachycardia and weight gain 

C. Hypothermia and constipation 

D. Moist skin and coarse hair 

Answer: C 

Explanation: Hypothyroidism causes decreased metabolic rate, which will cause lowered body temperature and pulse and decreased digestion of food. The skin is dry, and the hair thins. 

Question 5268) 

Which diet does the nurse expect will be ordered for the client with hypothyroidism? 

A. High protein, high calorie 

B. Restricted fluids, low protein 

C. High roughage, low calorie 

D. High carbohydrate, low roughage 

Answer: C 

Explanation: Hypothyroidism causes constipation and obesity. A diet high in roughage and low in calories is appropriate. The client should not be given a high-calorie diet. There is no need for fluid restriction or alteration in protein. 

Question 5269) 

An adult with myxedema is started on thyroid replacement therapy and is discharged. The client returns to the doctor’s office one week later. Which statement that the client makes is most indicative of an adverse reaction to the medication?  

A. “My chest hurt when I was sweeping the floor this morning

B. “I had severe cramps last night.” 

C. I am losing weight.” 

D. “My pulse rate has been more rapid lately.” 

Answer: A

Explanation: Chest pain on exertion suggests angina. In addition to a slow heart rate, the client with hypothyroidism frequently has atherosclerosis. Thyroxine will increase the heart rate, and the heart will require more oxygen. Angina is a likely and serious complication that can occur. She will also probably lose weight and have an increased pulse. These are expected when taking thyroxine. Cramps are not likely to be related to taking thyroxine. 

Question 5270) 

The nurse’s next door neighbor calls. He says he cannot awaken his 21-year-old wife. The nurse notes that the client is unconscious and is having deep respirations. Her breath has a fruity smell to it. The husband says that his wife has been eating and drinking a lot recently and that last night she vomited before lying down. What is the most appropriate action for the nurse to take? 

A. Start cardiopulmonary resuscitation 

B. Get her to a hospital immediately 

C. Try to rouse her by giving her coffee 

D. Give her sweetened orange juice 

Answer: B 

Explanation: Her symptoms suggest ketoacidosis. She must receive medical treatment at once. Coffee will not help her and is contraindicated because she is unresponsive. Sweetened orange juice is not indicated for ketoacidosis. It would be appropriate for hypoglycemia if the client is conscious. There is no indication for cardiopulmonary resuscitation.