Nursing Elites

1. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication dosage is too high?

• A. Increased sensitivity to cold.
• B. Increased heart rate and palpitations.
• C. Improved energy levels.
• D. Improved tolerance to heat.

Correct answer: B

Rationale: The correct answer is B: Increased heart rate and palpitations. When a client with hypothyroidism is prescribed levothyroxine, these symptoms may indicate that the dosage is too high, causing the client to develop hyperthyroidism. Choices A, C, and D are incorrect. Increased sensitivity to cold is a symptom of hypothyroidism, improved energy levels are an expected outcome of levothyroxine therapy for hypothyroidism, and improved tolerance to heat is not a common sign of levothyroxine overdose.

2. A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?

• A. Take the medication with meals to prevent gastrointestinal upset.
• B. Report any symptoms of nausea, vomiting, or diarrhea.
• C. Monitor lithium levels regularly and maintain hydration.
• D. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) while on lithium.

Correct answer: D

Rationale: The correct answer is D. Clients taking lithium should avoid NSAIDs as they can increase lithium levels leading to toxicity. It is essential to monitor lithium levels regularly and maintain hydration to prevent toxicity. Reporting symptoms like nausea, vomiting, or diarrhea is important, but the key teaching point regarding lithium toxicity is to avoid NSAIDs.

3. What information should the nurse include in the client's health record after a fall in the bathroom?

• A. Client fell while trying to go to the bathroom
• B. The UAP left the client alone and a fall occurred
• C. The client was found on the floor with no pulse
• D. The client fell, sustaining a fracture to the left hip

Correct answer: D

Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.

4. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

• A. A tuna fish sandwich with chips and ice cream
• B. A vegetable salad with croutons and ranch dressing
• C. A grilled chicken breast with steamed vegetables
• D. A peanut butter and jelly sandwich with soda

Correct answer: C

Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.

5. A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?

• A. Check the client's blood pressure.
• B. Assess for signs of bleeding.
• C. Assess the client's neurological status.
• D. Monitor the client's intake and output.

Correct answer: B

Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.

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