Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement?
A. Offer additional blankets and a warm drink.
Incorrect- While providing comfort measures like blankets and warm drinks can help the client feel more comfortable, they do not address the underlying thyroid hormone imbalance.
B. Note the client's most recent hemoglobin level.
Incorrect- Hemoglobin level is not directly related to the client's symptoms or the thyroid hormone imbalance. Monitoring hemoglobin is important in assessing anemia but is not the priority in this case.
C. Administer prescribed dose of levothyroxine.
Correct- The client's symptoms (raspy voice, cold intolerance, fatigue) along with an elevated TSH and low T3 and T4 levels suggest hypothyroidism. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. Administering the prescribed dose of levothyroxine is crucial to address the thyroid hormone imbalance and alleviate the symptoms.
D. Assess for presence of non-pitting edema.
Incorrect- Non-pitting edema is not a common symptom of hypothyroidism. The client's symptoms and lab results are more indicative of hypothyroidism, and addressing the thyroid hormone imbalance is the priority.
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Full Explanation
A) Incorrect- While providing comfort measures like blankets and warm drinks can help the client feel more comfortable, they do not address the underlying thyroid hormone imbalance.
B) Incorrect- Hemoglobin level is not directly related to the client's symptoms or the thyroid hormone imbalance. Monitoring hemoglobin is important in assessing anemia but is not the priority in this case.
C) Correct- The client's symptoms (raspy voice, cold intolerance, fatigue) along with an elevated TSH and low T3 and T4 levels suggest hypothyroidism. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. Administering the prescribed dose of levothyroxine is crucial to address the thyroid hormone imbalance and alleviate the symptoms.
D. Incorrect- Non-pitting edema is not a common symptom of hypothyroidism. The client's symptoms and lab results are more indicative of hypothyroidism, and addressing the thyroid hormone imbalance is the priority.
Similar Questions
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?
A. Tell the client to discuss the medication side effects with the healthcare provider.
The nurse supports client autonomy and ensures safe management. The provider can adjust the dose, switch medications, or address side effects appropriately.
B. Tell the client that the medication's side effects will most likely dissipate over time.
Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.
C. Inform the client that gradual tapering must be used to discontinue the medication.
Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression. While true that antidepressants require tapering to avoid withdrawal, this does not address the client's misconception that the medication is no longer needed because they feel improved.
D. Remind the client that feeling better is the therapeutic effect of the medication.
Although true, this response dismisses the client’s concern about side effects and does not address the request to discontinue.
E. None
None
F. None
None
Full Explanation
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A. Discuss with provider → Correct. The nurse supports client autonomy and ensures safe management. The provider can adjust the dose, switch medications, or address side effects appropriately.
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B. Side effects dissipate → Incorrect. Some antidepressant side effects improve, but others persist. This statement minimizes the client’s concerns and is not therapeutic.
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C. Gradual tapering → Incorrect. While tapering is necessary, the nurse should not instruct discontinuation independently. This is the provider’s role.
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D. Feeling better is therapeutic effect → Incorrect. Although true, this response dismisses the client’s concern about side effects and does not address the request to discontinue.
The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?
A. Side-lying with the head slightly elevated.
Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B. Standing with the head leaning backward.
Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C. Sitting up and leaning forward.
Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D. Supine with the legs raised.
Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.
Full Explanation
A) Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B) Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C) Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D) Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.
The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
A. An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours.
Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection.
Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery.
Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D. An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.
Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.
Full Explanation
A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.