Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
A. Hypotension
Hypotension, or low blood pressure, is not typically associated with thyroid storm. Thyroid storm is a life-threatening condition that often presents with hypertensive crisis due to the excessive amount of thyroid hormones accelerating the body's metabolism.
B. Increased temperature
Increased temperature is a hallmark sign of thyroid storm. Patients experiencing a thyroid storm can have a high fever, with temperatures ranging from 104°F to 106°F. This is due to the hypermetabolic state induced by excessive thyroid hormones, which increases the body's heat production.
C. Lethargy
Lethargy is not a common symptom of thyroid storm. Instead, patients may experience agitation, irritability, and anxiety due to the overstimulation of the nervous system by excessive thyroid hormones. Lethargy might be observed in hypothyroidism, which is the opposite condition.
D. Decreased heart rate
A decreased heart rate is not characteristic of thyroid storm. On the contrary, tachycardia, or a rapid heart rate, is a common symptom. The heart rate can exceed 140 beats per minute as the body's demand for oxygen increases due to the hypermetabolic state.
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Full Explanation
Choice A reason: Hypotension, or low blood pressure, is not typically associated with thyroid storm. Thyroid storm is a life-threatening condition that often presents with hypertensive crisis due to the excessive amount of thyroid hormones accelerating the body's metabolism.
Choice B reason: Increased temperature is a hallmark sign of thyroid storm. Patients experiencing a thyroid storm can have a high fever, with temperatures ranging from 104°F to 106°F. This is due to the hypermetabolic state induced by excessive thyroid hormones, which increases the body's heat production.
Choice C reason: Lethargy is not a common symptom of thyroid storm. Instead, patients may experience agitation, irritability, and anxiety due to the overstimulation of the nervous system by excessive thyroid hormones. Lethargy might be observed in hypothyroidism, which is the opposite condition.
Choice D reason: A decreased heart rate is not characteristic of thyroid storm. On the contrary, tachycardia, or a rapid heart rate, is a common symptom. The heart rate can exceed 140 beats per minute as the body's demand for oxygen increases due to the hypermetabolic state.
Similar Questions
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
A. Clear items from the client's surrounding area.
Clearing items from the client's surrounding area is important, but it is not the first action a nurse should take. The priority is to prevent injury to the client, and while removing potential hazards is part of this, it comes after ensuring the client's immediate safety.
B. Loosen the client's restrictive clothing.
Loosening restrictive clothing can help the client breathe more easily and prevent further injury. However, this is not the first step in seizure first aid. The initial focus should be on preventing injury by controlling the client's fall.
C. Lower the client to the floor.
Lowering the client to the floor is the first and most critical action to take. This prevents a fall that could result in serious injury. Once on the floor, the client should be turned gently onto one side to help maintain an open airway and allow any fluids to drain, which can help prevent aspiration.
D. Obtain the client's vital signs.
Obtaining the client's vital signs is a secondary action after the seizure has ended. During a seizure, the primary concern is the client's immediate safety, which includes preventing injury and maintaining an open airway.
Full Explanation
Choice A reason: Clearing items from the client's surrounding area is important, but it is not the first action a nurse should take. The priority is to prevent injury to the client, and while removing potential hazards is part of this, it comes after ensuring the client's immediate safety.
Choice B reason: Loosening restrictive clothing can help the client breathe more easily and prevent further injury. However, this is not the first step in seizure first aid. The initial focus should be on preventing injury by controlling the client's fall.
Choice C reason: Lowering the client to the floor is the first and most critical action to take. This prevents a fall that could result in serious injury. Once on the floor, the client should be turned gently onto one side to help maintain an open airway and allow any fluids to drain, which can help prevent aspiration.
Choice D reason: Obtaining the client's vital signs is a secondary action after the seizure has ended. During a seizure, the primary concern is the client's immediate safety, which includes preventing injury and maintaining an open airway.
A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?
A. A client who has a headache following a grade 1 concussion.
A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.
B. A client who has experienced brain death and is awaiting organ procurement.
A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.
C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash.
A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.
D. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack.
A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.
Full Explanation
Choice A reason: A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.
Choice B reason: A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.
Choice C reason: A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.
Choice D reason: A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.
A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
A. Wear sterile gloves when collecting the sample.
While wearing gloves is a standard precaution to prevent contamination and protect the nurse from potential pathogens, the gloves used for collecting a guaiac smear sample do not need to be sterile. Clean, non-sterile gloves are typically sufficient for this procedure.
B. Discard samples that contain urine.
It is crucial to discard any samples that contain urine because urine can interfere with the results of the fecal occult blood test (FOBT). The presence of urine can cause false positives due to the peroxidase activity in urine, which can lead to unnecessary further testing.
C. Collect three samples from a single bowel movement.
Collecting three samples from a single bowel movement is not recommended. Instead, it is advised to collect samples from three separate bowel movements to increase the likelihood of detecting intermittent bleeding, which is common in conditions like colorectal cancer.
D. Take the sample from the outer edge of formed stool.
Taking the sample from the outer edge of formed stool is not the best practice. The sample should be taken from different areas of the stool to ensure a representative sample, as blood may not be uniformly distributed throughout the stool.
Full Explanation
Choice A reason: While wearing gloves is a standard precaution to prevent contamination and protect the nurse from potential pathogens, the gloves used for collecting a guaiac smear sample do not need to be sterile. Clean, non-sterile gloves are typically sufficient for this procedure.
Choice B reason: It is crucial to discard any samples that contain urine because urine can interfere with the results of the fecal occult blood test (FOBT). The presence of urine can cause false positives due to the peroxidase activity in urine, which can lead to unnecessary further testing.
Choice C reason: Collecting three samples from a single bowel movement is not recommended. Instead, it is advised to collect samples from three separate bowel movements to increase the likelihood of detecting intermittent bleeding, which is common in conditions like colorectal cancer.
Choice D reason: Taking the sample from the outer edge of formed stool is not the best practice. The sample should be taken from different areas of the stool to ensure a representative sample, as blood may not be uniformly distributed throughout the stool.