A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

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Question 1 of 5

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

Correct Answer: C

Rationale: Exophthalmos requires quick intervention in Graves'. Bulging eyes signal thyroid orbitopathy, needing urgent referral to prevent vision loss. Weight loss , restlessness , and irritability are managed less acutely. C prioritizes complication, making it critical.

Question 2 of 5

The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first?

Correct Answer: B

Rationale: Using minimal physical contact is first for a toddler. It builds trust, reducing fear, per development. Traumatic procedures , head-to-toe , or explanation follow. B ensures cooperation, making it initial.

Question 3 of 5

The nurse is assessing a client with a suspected bowel obstruction. Which finding should the nurse report immediately to the health care provider?

Correct Answer: B

Rationale: High-pitched bowel sounds need immediate reporting in suspected bowel obstruction. They indicate hyperperistalsis from blockage, risking perforation, per pathophysiology. Nausea , mild pain , and 12-hour stool absence are less urgent. B signals progression, making it critical.

Question 4 of 5

A client who is receiving IV gentamicin for a wound infection says to the nurse, 'I've been having some trouble hearing lately.' Which action should the nurse take first?

Correct Answer: B

Rationale: Notifying the provider immediately is first. Hearing trouble with gentamicin suggests ototoxicity, a serious side effect needing urgent review, per protocol. Asking , documenting , or assessing delays intervention. B ensures safety, making it priority.

Question 5 of 5

A client with MRSA is placed on contact precautions. Which instruction should the nurse give to the unlicensed assistive personnel (UAP) assisting with care?

Correct Answer: B

Rationale: Wash hands with soap and water after removing gloves' is key for MRSA contact precautions. Soap removes spores, per CDC, unlike alcohol . Gloves/gown are standard, mask unnecessary unless airborne risk. B prevents spread, making it best.

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