Nursing Elites

1. The nurse is caring for a client with hyperthyroidism. Which assessment finding requires immediate intervention?

• A. Heart rate of 100 beats per minute.
• B. Blood pressure of 150/90 mm Hg.
• C. Respiratory rate of 24 breaths per minute.
• D. Weight loss of 5 pounds in one week.

Correct answer: D

Rationale: Weight loss of 5 pounds in one week in a client with hyperthyroidism is concerning as it may indicate severe hypermetabolism, leading to potential complications such as cardiac arrhythmias, muscle weakness, and other metabolic disturbances. Rapid weight loss in hyperthyroidism indicates an accelerated metabolic rate and increased energy expenditure, which can be detrimental to the client's health. The other assessment findings (heart rate of 100 beats per minute, blood pressure of 150/90 mm Hg, respiratory rate of 24 breaths per minute) are commonly seen in clients with hyperthyroidism and may not necessarily require immediate intervention unless they are significantly outside the normal range or causing distress to the client.

2. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?

• A. Jaundice.
• B. Ascites.
• C. Peripheral edema.
• D. Spider angiomas.

Correct answer: D

Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.

3. The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?

• A. Weight gain of 1 pound.
• B. Dizziness.
• C. Fatigue.
• D. Muscle cramps.

Correct answer: D

Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.

4. A female client reports to the nurse that her sleep was interrupted by 'thoughts of anger towards my husband.' What type of thoughts is the client having?

• A. Obsessive.
• B. Phobic.
• C. Delusional.
• D. Paranoid.

Correct answer: A

Rationale: The correct answer is A: Obsessive. Obsessive thoughts are recurring, unwanted, and intrusive thoughts that cause distress or anxiety. In this scenario, the client is experiencing repetitive thoughts of anger towards her husband, indicating an inability to control these thoughts. Choice B, Phobic, is incorrect as phobic thoughts are related to irrational fears. Choice C, Delusional, is incorrect as delusional thoughts involve fixed false beliefs. Choice D, Paranoid, is incorrect as paranoid thoughts involve irrational suspicions and mistrust.

5. During a home visit, the nurse observes that a client with limited mobility has difficulty preparing meals. What should the nurse do first?

• A. suggest that the client use a meal delivery service
• B. assist the client in meal planning
• C. refer the client to a dietitian
• D. educate the client on easy-to-prepare healthy meals

Correct answer: B

Rationale: Assisting the client in meal planning is the most appropriate initial action as it addresses the immediate issue of meal preparation. By helping the client plan meals according to their dietary needs and limitations, the nurse can support the client in maintaining a healthy diet despite limited mobility. While suggesting a meal delivery service (Choice A) may be a viable option, assisting in meal planning allows for more personalized and sustainable solutions. Referring the client to a dietitian (Choice C) may be necessary for specialized nutritional advice but is not the first step in addressing the immediate concern. Educating the client on easy-to-prepare healthy meals (Choice D) could be beneficial, but meal planning is a more comprehensive approach to ensure the client's dietary needs are met consistently.

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