Exam 2

Question 1

The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which?

A. promote oxygen intake
B. Strengthen the diaphragm
C. strengthen the intercostal muscles
D. promote carbon dioxide elimination

Answer 1

A. promote carbon dioxide elimination

Question 2

The nurse is caring for a client with emphysema receiving oxygen. The nurse should check the oxygen flow rate to ensure the client does not exceed how many L/minute of oxygen?
A. 1
B. 2
C. 6
D. 10

Answer 2

B. 2

Question 3

The nurse assesses a patient with emphysema and notes a barrel chest. What is the reason for this patient’s chest anomaly?

A. Collapse of distal alveoli
B. Use of accessory muscles
C. Hyperinflation of the lungs
D. Long-term, chronic hypoxia

Answer 3

C. Hyperinflation of the lungs

Question 4

The student nurse is preparing a report about COPD. The student would be correct in including which disease(s) in the report? (Select all that apply.)

A. Emphysema
B. Bronchial asthma
C. Chronic bronchitis
D. Pleurisy with effusion
E. Pulmonary tuberculosis

Answer 4

A. Emphysema

B. Bronchial asthma

Question 5

A nurse is caring for a patient who has asthma. Which lung sound would the nurse expect to hear when auscultating this patients lung fields?

A. fine crackles
B. stridor
C. pleural friction rub
D. wheezes

Answer 5

D. wheezes

Question 6

The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?

1. Complaints of extreme fatigue and hair loss.
2. Exophthalmos and complaints of nervousness.
3. Complaints of profuse sweating and flushed skin.
4. Tetany and complaints of stiffness of the hands.

Answer 6

1.A decrease in thyroid hormone causes decreased metabolism, which leads to fatigue and hair loss.

2. These are signs of hyperthyroidism.
3. These are signs of hyperthyroidism.
4. These are signs of parathyroidism

Question 7

The nurse identifies the client problem “risk for imbalanced body temperature” fort he client diagnosed with hypothyroidism. Which intervention should be included in the plan of care?

1. Discourage the use of an electric blanket.
2. Assess the client’s temperature every two (2) hours.
3. Keep the room temperature cool.
4. Space activities to promote rest.

Answer 7

1.External heat sources (heating pads,electric or warming blankets) should be discouraged because they increase the risk of peripheral vasodilation and vascular collapse.

2. Assessing the client’s temperature every two (2) hours is not needed because the temperature will not change quickly. The client needs thyroid hormones to help increase the client’s temperature.
3. The room temperature should be kept warm because the client will have complaints of being cold.
4. The client is fatigued and this is an appropriate intervention, but is not applicable to the client problem of “risk for imbalanced body temperature.”

Question 8

The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective?

1. The client has a three (3)-pound weight gain.
2. The client has a decreased pulse rate.
3. The client’s temperature is WNL.
4. The client denies any diaphoresis.

Answer 8

3.The client with hypothyroidism frequently has a subnormal temperature, so a temperature WNL indicates the medication is effective.

1. The medication will help increase the client’s metabolic rate. A weight gain indicates not enough medication is being taken to put the client in a euthyroid (normal thyroid) state.
2. A decreased pulse rate indicates there is not enough thyroid hormone level; therefore, the medication is not effective.
3. Diaphoresis (sweating) occurs with hyper-thyroidism, not hypothyroidism

Question 9

Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism?

1. Increase the amount of fiber in the diet.
2. Encourage a low-calorie, low-protein diet.
3. Decrease the client’s fluid intake to 1,000 mL/day.
4. Provide six (6) small, well-balanced meals a day.

Answer 9

4.The client with hyperthyroidism has an increased appetite; therefore, well-balanced meals served several times throughout the day will help with the client’s constant hunger

1. Fiber should be increased in the client diagnosed with hypothyroidism because the client experiences constipation secondary to decreased metabolism.
2. The client with hyperthyroidism should have a high-calorie, high-protein diet.
3. The client’s fluid intake should be increased to replace fluids lost through diarrhea and excessive sweating.

Question 10

The client is admitted to the intensive care department diagnosed with myxedemacoma. Which assessment data warrant immediate intervention by the nurse?

1. Serum blood glucose level of 74 mg/dL.
2. Pulse oximeter reading of 90%.
3. Telemetry reading showing sinus bradycardia.
4. The client is lethargic and sleeps all the time.

Answer 10

2.A pulse oximeter reading of less than 93% is significant. A 90% pulse oximeter reading indicates a PaO2 of approximately 60 on an arterial blood gas test; this is severe hypoxemia and requires immediate intervention.

1. Hypoglycemia is expected in a client with myxedema; therefore, a 74-mg/dL blood glucose level is expected.
2. The client with myxedema coma is in an exaggerated hypothyroid state; a low pulse is expected in a client with hypothyroidism.
3. Lethargy is an expected symptom in a client diagnosed with myxedema; there-fore, this does not warrant immediate intervention

Question 11

Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism?

1. Thyroid hormones.
2. Oxygen.
3. Sedatives.
4. Laxatives.

Answer 11

3.Untreated hypothyroidism is characterized by an increased susceptibility to the effects of most hypnotic and sedative agents; therefore, the nurse should question this medication.

1. Thyroid hormones are the treatment of choice for the client diagnosed with hypothyroidism; therefore, the nurse should not question this medication.
2. In untreated hypothyroidism, the medical management is aimed at supporting vital functions, so administering oxygen is an appropriate medication.
3. Clients with hypothyroidism become constipated as a result of decreased metabolism, so laxatives should not be questioned by the nurse.

Question 12

Which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism?

1. “I just don’t seem to have any appetite anymore.”
2. “I have a bowel movement about every 3 to 4 days.”
3. “My skin is really becoming dry and coarse.”
4. “I have noticed all my collars are getting tighter.”

Answer 12

4. The thyroid gland (in the neck) en-larges as a result of the increased need for thyroid hormone production; an enlarged gland is called a goiter.
5. Decreased appetite is a symptom of hypothyroidism, not hyperthyroidism.
6. Constipation is a symptom of hypothyroidism.
7. Dry, coarse skin is a sign of hypothyroidism

Question 13

The 68-year-old client diagnosed with hyperthyroidism is being treated with radio active iodine therapy. Which interventions should the nurse discuss with the client?

1. Explain it will take up to a month for symptoms of hyperthyroidism to subside.
2. Teach the iodine therapy will have to be tapered slowly over one (1) week.
3. Discuss the client will have to be hospitalized during the radioactive therapy.
4. Inform the client after therapy the client will not have to take any medication.

Answer 13

1.Radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the client is followed closely for three (3) to four (4) weeks until the euthyroid state is reached.

2. A single dose of radioactive iodine therapyis administered; the dosage is based on theclient’s weight.
3. The colorless, tasteless radioiodine is administered by the radiologist, and theclient may have to stay up to two (2) hoursafter the treatment in the office.
4. If too much of the thyroid gland is destroyed by the radioactive iodine therapy, the client may develop hypothy-roidism and have to take thyroid hormonethe rest of his or her life

Question 14

Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm?

1. Obstipation and hypoactive bowel sounds.
2. Hyperpyrexia and extreme tachycardia.
3. Hypotension and bradycardia.
4. Decreased respirations and hypoxia.

Answer 14

2. Hyperpyrexia (high fever) and heart rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism.
3. These are signs of myxedema (hypothyroidism) coma. Obstipation is extreme constipation.
4. Decreased blood pressure and slow heartrate are signs of myxedema coma.
5. These are signs/symptoms of myxedema coma.

Question 15

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially?

1. Warm the client.
2. Maintain a patent airway.
3. Administer thyroid hormone.
4. Administer fluid replacement.

Answer 15

2. Maintain patient airway

Question 16

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply.

1. Tremors
2. Weight loss
3. Feeling cold
4. Loss of body hair
5. Persistent lethargy
6. Puffiness of the face

Answer 16

3. Feeling cold
4. Loss of body hair
5. Persistent lethargy
6. Puffiness of the face

Question 17

A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply.

1. Fever
2. Nausea
3. Lethargy
4. Tremors
5. Confusion
6. Bradycardia

Answer 17

1. Fever
2. Nausea
3. Tremors
4. Confusion

Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

Question 18

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply.

1. Provide a cool environment for the client.
2. Instruct the client to consume a high-fat diet.
3. Instruct the client about thyroid replacement therapy.
4. Encourage the client to consume fluids and high-fiber foods in the diet.
5. Inform the client that iodine preparations will be prescribed to treat the disorder.
6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur

Answer 18

3. Instruct the client about thyroid replacement therapy.
4. Encourage the client to consume fluids and high-fiber foods in the diet.
5. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur