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Extract:

Ms. Wilson is a 45-year-old female presents to the clinic with unexplained weight loss, anxiety, heat intolerance and palpitations. Exams reveal mild systolic hypertension, exophthalmos, lid lag, non-pitting leg edema, and a diffusely enlarged painless thyroid gland. Lab results showed depressed TSH and borderline T3 and T4. Hyperthyroidism was confirmed.


Question 1 of 5

As a result of low levels of T3 and T4, the nurse should expect Ms. Wilson to exhibit:

Correct Answer: C

Rationale: Decreased production of thyroid hormones lowers metabolism, which leads to intolerance to cold. However, the question seems to misalign with the hyperthyroidism diagnosis; in hyperthyroidism, T3 and T4 are elevated, but the answer choices suggest hypothyroidism. Given the options, cold intolerance is the correct choice for low T3/T4.

Extract:


Question 2 of 5

The nurse is caring for an adult who had a transsphenoidal hypophysectomy earlier today. The client is now on the surgical unit after an uneventful stay in the postanesthesia care unit. How should the nurse position the client?

Correct Answer: C

Rationale: Semi-reclining reduces intracranial pressure and prevents cerebrospinal fluid leakage post-transsphenoidal hypophysectomy. Supine increases leakage risk, and upright or side-lying are less optimal.

Question 3 of 5

The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the provider?

Correct Answer: D

Rationale: Falls forward when sitting. Sitting without support is expected at 8 months, indicating a developmental concern.

Extract:

The nurse documents and performs which of the following when the patient refuses his medication?


Question 4 of 5

Kardex; physician.

Correct Answer: C

Rationale: Documenting in the medication record and progress notes, and informing the physician, ensures accurate communication.

Extract:


Question 5 of 5

An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks: 'When can the tube can be used for feeding?' The nurse's best response would be which of these comments?

Correct Answer: C

Rationale: The stomach contents and air must be drained first.' After surgery for gastrostomy tube placement, the catheter is left open and attached to gravity drainage for 24 hours or more.

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