The nurse has reviewed the Vital Signs at 1000.

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"}}

• Apply cooling blanket: The client has an elevated temperature (38.3°C/100.9°F), which could suggest early signs of thyroid storm, a life-threatening complication after thyroid surgery. Applying a cooling blanket is an appropriate non-pharmacological intervention to help manage hyperthermia without medications that could worsen symptoms.

• Monitor vital signs every 4 hours: Frequent monitoring of vital signs is critical after thyroidectomy to detect early signs of complications such as thyroid storm, hemorrhage, or airway compromise. Vital sign changes can provide early warning signs of clinical deterioration and allow for rapid intervention.

• Place client on telemetry: Thyroid storm and other thyroid-related crises can cause arrhythmias, including tachycardia and atrial fibrillation. Continuous cardiac monitoring is anticipated to quickly detect and manage any rhythm disturbances that may arise postoperatively.

• Palpate thyroid area to assess for hematoma: After a thyroidectomy, it is essential to assess for hematoma formation, as hematomas can compress the airway and become life-threatening. Regular palpation of the surgical site helps detect swelling, firmness, or respiratory distress early.

• Administer aspirin for fever: Aspirin is not recommended for fever management in postoperative thyroidectomy clients because it can displace thyroid hormones from binding proteins, potentially worsening thyrotoxicosis. Fever should be managed with other antipyretics like acetaminophen or physical cooling methods instead.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Flight of ideas: Flight of ideas is a classic finding in clients experiencing a manic episode of bipolar disorder. It is characterized by rapid, continuous shifts from one topic to another, often making it difficult for the listener to follow the conversation. This reflects the elevated mood and pressured speech typical of mania.

B. Ritualistic behavior: Ritualistic behaviors, such as repetitive actions or strict routines, are more commonly associated with obsessive-compulsive disorder (OCD) rather than bipolar disorder. While clients with bipolar disorder may show disorganized behavior during mania, ritualism is not a hallmark feature.

C. Well-groomed appearance: During manic or depressive episodes of bipolar disorder, clients often experience a decline in self-care and grooming. A consistently well-groomed appearance would be more typical of a stable, euthymic phase rather than during an active mood episode.

D. Command hallucinations: Command hallucinations are typically linked to psychotic disorders such as schizophrenia. Although severe mania can include psychotic features, hallucinations are not a primary or consistent symptom in bipolar disorder unless it becomes a psychotic manic or depressive episode.

A. Inability to read B. Echopraxia C. Acute onset of confusion D. Aphasia

Correct Answer is C

Explanation

A. Inability to read: Difficulty reading is not a hallmark symptom of delirium. It may be associated with visual impairment, literacy issues, or chronic cognitive decline such as dementia, but delirium is primarily characterized by acute mental status changes, not isolated reading difficulties.

B. Echopraxia: Echopraxia, the involuntary imitation of another person’s movements, is typically associated with schizophrenia or other severe psychiatric disorders. It is not a defining feature of delirium, which primarily affects attention, awareness, and cognition rather than imitation behaviors.

C. Acute onset of confusion: Delirium is distinguished by a sudden, acute onset of confusion and fluctuating levels of consciousness. Clients may exhibit disorganized thinking, poor attention, and impaired awareness, which are hallmark features that help differentiate delirium from chronic conditions like dementia.

D. Aphasia: Aphasia, or loss of the ability to understand or express speech, is more commonly related to neurological injuries such as stroke. While speech may be disorganized during delirium, the specific loss of language function like aphasia is not a primary or expected feature of this acute condition.

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The nurse has reviewed the Vital Signs at 1000. 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 collecting data from a client who has bipolar disorder. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

The nurse is continuing to assist with the care of the client. Select words from the choices below to fill in each blank in the following sentence. The complications that the client is at greatest risk for developing are ______ and ______

A nurse is collecting data from a client who is experiencing ketoacidosis. Which of the following manifestations should the nurse expect to find?

A nurse is collecting data from a client about range-of-motion for various joints. Which of the following images should the nurse identity as an example of a ball and socket joint?

A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply)

A nurse is caring for a client who has toxoplasmosis and asks about the cause of the infection. Which of the following responses should the nurse make?

The nurse is reviewing the findings. For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. Complete the following sentence by using the lists of options. The nurse should first address the client's _____ followed by the client's ______.

The nurse has reviewed the Vital Signs at 1000.

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