The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:

Correct Answer: D

Rationale: The correct assessment findings to stay alert for when evaluating for hypothyroidism are decreased body temperature and cold intolerance. Hypothyroidism is a condition characterized by an underactive thyroid gland, leading to a decrease in metabolic rate. This can result in symptoms such as feeling cold all the time and a lower body temperature. Therefore, the nurse should keep an eye out for these symptoms during the assessment of a client being evaluated for hypothyroidism. Symptoms such as exophthalmos and conjunctival redness are more commonly associated with hyperthyroidism.

Correct Answer: D

Rationale: Advanced age is a nonmodifiable risk factor for diabetes mellitus. Nonmodifiable risk factors are characteristics or traits that cannot be changed or controlled. In this case, a person's age is a factor that continuously increases as time passes and cannot be altered. Other nonmodifiable risk factors for diabetes mellitus include family history of diabetes and certain ethnic backgrounds. On the other hand, poor control of blood glucose levels, current or recent foot trauma, and inappropriate foot care are examples of modifiable risk factors that can be managed through lifestyle changes and proper medical care.

Correct Answer: C

Rationale: The food pyramid can help guide the client on his diet by suggesting daily food choices. The food pyramid categorizes different food groups based on their nutritional compositions and recommended daily servings. By following the food pyramid, the client can make informed choices about what types and amounts of food to consume each day to achieve a balanced and healthy diet. The visual representation of the food pyramid also helps in understanding the relative proportions of different food groups that are part of a nutritious diet.

Correct Answer: D

Rationale: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for transmitting auditory and balance information from the inner ear to the brain. Complaints of hearing ringing noises, also known as tinnitus, suggest a dysfunction or injury to the vestibulocochlear nerve. Tinnitus is a common symptom of various inner ear disorders such as noise-induced hearing loss, Meniere's disease, or acoustic neuroma. Therefore, the nurse should investigate further for possible issues related to the vestibulocochlear nerve when a patient reports hearing ringing noises.

Correct Answer: D

Rationale: In the acute stage of an unconscious patient like Mr. Franco, the most critical assessment is ensuring the patency of the airway and evaluating the adequacy of respiration. Maintaining a clear airway is essential to ensure that oxygen can reach the lungs and be circulated to vital organs. Without proper airway management, a patient's condition can quickly deteriorate due to hypoxia, leading to severe complications or even death. Therefore, assessing and securing the airway is the priority in the initial management of an unconscious patient to maintain adequate oxygenation and ventilation. Monitoring the respiration rate, depth, and effort is crucial to identify any signs of respiratory distress or failure that require immediate intervention. Once the airway and breathing are addressed, further assessments related to neurological function and sensory responses can be conducted.