A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

"The client's partner visited earlier today for 2 hours."

"The client received the prescribed antibiotic every 8 hours."

"The client's mother died 4 years ago from breast cancer."

"The client reports pain is reduced when he is positioned on his side.”

Answer and Explanation

The Correct Answer is D

Rationale:

A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.

B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.

C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.

D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

• Report of menstrual cycle: The client’s last menstrual period was 3 months ago, indicating amenorrhea. This is commonly seen in hyperthyroidism due to hormonal imbalances that interfere with normal menstrual regulation.

• Weight change: She reports a 3-month history of unintentional weight loss with a good appetite, which reflects the increased metabolic rate typically caused by elevated thyroid hormone levels in hyperthyroidism.

• Skin condition: Her skin is described as warm and moist, which is consistent with hyperthyroidism. Excess thyroid hormone increases heat production and stimulates the sweat glands.

• Neck exam: The presence of a visible goiter suggests thyroid gland enlargement, often due to overstimulation by thyroid-stimulating immunoglobulins in autoimmune hyperthyroidism like Graves' disease. A goiter can occur in Hypothyroidism (e.g., Hashimoto's thyroiditis) as the gland tries to compensate. Therefore, this finding is consistent with both.

• Laboratory results: Elevated T3 (230 ng/dL), free T4 (3.4 ng/dL), and TSI (150%) confirm hyperthyroidism. These values exceed the normal range and strongly indicate an overactive thyroid gland.

• Eye appearance: Exophthalmos (protruding eyes) is observed, a hallmark of Graves’ disease. This autoimmune feature is linked exclusively to hyperthyroidism and is caused by inflammation and tissue buildup behind the eyes.

A. "Discontinue the medication. I will ask your provider for another antibiotic." B. "That reaction means your dose is too high. Cut the pill in half." C. "Continue to take the medication. Calf pain is a minor reaction that will resolve itself." D. “This is an allergic reaction. Take the medication with an antihistamine."

Correct Answer is A

Explanation

Rationale:

A. "Discontinue the medication. I will ask your provider for another antibiotic.": Calf pain in a client taking ciprofloxacin may indicate tendinitis or even tendon rupture, a serious adverse effect associated with fluoroquinolones. The nurse should advise discontinuation of the drug and alert the provider immediately to prevent permanent damage.

B. "That reaction means your dose is too high. Cut the pill in half.": Reducing the dose without provider approval is unsafe and does not address the underlying risk of tendon injury. Ciprofloxacin-related tendinopathy is not dose-dependent and requires immediate discontinuation.

C. "Continue to take the medication. Calf pain is a minor reaction that will resolve itself.": Calf pain during ciprofloxacin therapy should never be dismissed as minor, since it may signal tendon inflammation or rupture.

D. “This is an allergic reaction. Take the medication with an antihistamine.": Tendon-related adverse effects are not allergic reactions and will not respond to antihistamines. Misclassifying the symptom as an allergy delays the proper intervention and increases the risk of irreversible tendon damage.

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A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in a provider's clinic. Exhibits For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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