The nurse has reviewed the Vital Signs at 1000.

Exhibits
For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Administer aspirin for fever

Apply cooling blanket

Monitor vital signs every 4 hours

Place client on telemetry

Palpate thyroid area to assess for hematoma

Answer and Explanation

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

Rationale:

• Administer aspirin for fever: Aspirin can increase circulating thyroid hormones by displacing T4 and T3 from protein-binding sites. In a hyperthyroid or recently post-thyroidectomy patient, this may precipitate or worsen a thyroid storm. Acetaminophen is a safer antipyretic choice.

• Apply cooling blanket: The client’s postoperative fever (38.3°C), elevated heart rate (98/min), and history of hyperthyroidism indicate a risk for thyroid storm. External cooling is a supportive measure to manage hyperthermia during this critical period.

• Monitor vital signs every 4 hours: This is anticipated to detect signs of complications such as thyroid storm, hemorrhage, or airway compromise. Postoperative clients require close observation to identify early changes in temperature, pulse, or respiration.

• Place client on telemetry: Cardiac monitoring is essential after thyroidectomy in clients with a history of hyperthyroidism. Increased metabolic demand, fever, and potential for arrhythmias justify continuous cardiac observation.

• Palpate thyroid area to assess for hematoma: A neck hematoma is a potentially life-threatening complication of thyroid surgery. It can lead to airway obstruction. Palpation and inspection for swelling or firmness around the incision site are critical nursing assessments.

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Correct Answer is B

Explanation

Rationale:

A. Direct questions to the interpreter: Communication should be directed to the client, not the interpreter. Speaking directly to the client fosters rapport and respects their autonomy, while the interpreter facilitates understanding.

B. Ask the client for regular feedback: Checking in frequently with the client ensures they understand the information being conveyed. This helps clarify misunderstandings and confirms effective communication through the interpreter.

C. Incorporate acronyms into client teaching: Using acronyms can confuse clients, especially those with limited English proficiency or unfamiliarity with medical terminology. Clear, simple language without jargon is preferred.

D. Ask the client's family member to interpret: Family members may lack medical terminology knowledge, may filter information, or breach confidentiality. Professional interpreters provide more accurate and unbiased communication.

A. past medical history B. illusions C. change in orientation D. hallucinations

Correct Answer is ["C","D"]

Explanation

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.

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The nurse has reviewed the Vital Signs at 1000. Exhibits For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who needs an interpreter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client in the intensive care unit (ICU) Exhibits The nurse should identify which of the following client's conditions can indicate the development of delirium.

Correct Answer is ["C","D"]

Explanation

A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Complete the following sentence by using the list of options. Exhibits The nurse should first anticipate the need to dropdown and then dropdown.

A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?

A nurse is reinforcing teaching with the guardian of a newborn about measures that can be taken to minimize the risk of sudden unexpected infant death (SUID). Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a 36-year-old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse should include in the teaching that an amniocentesis is performed to identify which of the following findings?

A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication?

A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

The nurse has reviewed the Vital Signs at 1000.

Exhibits
For each potential provider prescription, click to specify if the prescription is anticipated or non-anticipated for the client.