The nurse has reviewed the Nurses' Notes and Vital Signs at 0900.

Complete the following sentence by using the lists of options.

The client is most at risk for

due to

.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

seizures: If a thyroid storm occurs, the client can experience seizures due to the extreme metabolic disturbances and nervous system overstimulation it causes. Seizures would be a serious complication indicating worsening neurological function. Therefore, the client’s risk for seizures is directly related to the risk of developing a thyroid storm after surgery.
paralytic ileus: Paralytic ileus involves bowel inactivity post-surgery, but the client had normoactive bowel sounds before surgery and no current documentation of absent or significantly reduced bowel activity. Therefore, this is not the most immediate risk based on current findings.
pneumonia: The client is receiving oxygen therapy and has a slightly increased respiratory rate after surgery, but no signs of labored breathing, abnormal lung sounds, or infection are reported. Although inactivity can contribute to pneumonia risk postoperatively, there are no current findings indicating that pneumonia is developing right now.
thyroid storm: The client had a thyroidectomy after presenting with signs of severe hyperthyroidism (weight loss, heat intolerance, anxiety, exophthalmos, goiter) and elevated T3 and T4 levels. Thyroid storm is a critical risk after thyroidectomy due to sudden hormone release, and it can cause life-threatening complications such as high fever, hypertension, tachycardia, and altered mental status.
bowel sounds: The bowel sounds were normal before surgery, and there is no mention of significant gastrointestinal changes postoperatively. Bowel sounds alone are not the critical factor leading to the client’s highest current risk.
inactivity: The client is currently lethargic after surgery and under the effects of anesthesia, which reduces movement and activity. Inactivity can cause decreased lung expansion and increase the risk of pulmonary complications like pneumonia. Although this is a concern, inactivity is not the client's most critical immediate risk compared to thyroid storm.

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Correct Answer is C

Explanation

A. The infant was born large for gestational age: Being large for gestational age is not recognized as a risk factor for child maltreatment. Risk factors are more often related to family dynamics, age, and social stressors rather than birth weight alone.

B. The infant has otitis media: Otitis media, or a middle ear infection, is a common pediatric illness and is not itself a risk factor for maltreatment. It reflects normal childhood health issues rather than abuse or neglect.

C. The infant is younger than 1 year of age: Infants under 1 year are particularly vulnerable to maltreatment because of their total dependence on caregivers and inability to communicate effectively. This age group is at the highest risk for serious injury from abuse.

D. The infant's guardians are both over the age of 30: Parental age over 30 does not inherently increase the risk for child maltreatment. Other factors like substance abuse, history of being abused, and high stress levels are more closely linked to maltreatment risk.

A. <p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture5A_1746709389.jpg" class="img-fluid" /></p> B. <p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture5AB_1746709427.jpg" class="img-fluid" /></p>

Correct Answer is A

Explanation

A: Image A shows an injection being prepared at the deltoid muscle, which is the correct site and technique for administering the tetanus and diphtheria (Td) vaccine. The Td vaccine should be given intramuscularly, typically into the deltoid muscle of the upper arm in adults, using a 90-degree angle to ensure proper muscle penetration.

B: Image B shows an injection technique appropriate for intradermal or possibly subcutaneous injection, indicated by the shallow angle of insertion into the skin. This method is not correct for a Td vaccine, which requires intramuscular administration for proper absorption and effectiveness.

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for ________ due to ________.

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A nurse is contributing to the development of an in-service training about child maltreatment for a group of pediatric nurses. Which of the following findings should the nurse identify as a risk factor for child maltreatment?

Correct Answer is C

Explanation

A nurse is preparing to administer a tetanus and diphtheria toxoids (Td) to a client. Which of the following images indicates the technique nurse should plan to use?

Correct Answer is A

Explanation

A nurse is caring for a 2-year-old male client. The parent states, "He has started playing with dolls since our baby was born. Does this indicate he will identify as a female as he grows up?" Which of the following responses should the nurse make?

A nurse is contributing to the plan of care for a client who has a new ileostomy. Which of the following actions should the nurse include?

A nurse is assisting the guardians of a newborn with the transition to parenthood. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is at 30 weeks of gestation and has tuberculosis. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client in a provider's clinic. 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.

A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is assisting with the plan of care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional conference?

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900.

Complete the following sentence by using the lists of options.

The client is most at risk for

due to

.