Question

47. A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse includes in the teaching?

1. Hypotension
2. Increased temperature
3. Decreased heart rate
4. Lethargy

48. A nurse is caring for a female client who is receiving total parenteral nutrition without fat emulsion. Which of the following findings should the nurse report?

1. Bowel sounds absent in lower quadrants
2. Crackles in the bilateral lung bases
3. Weight gain of 1.3 kg (3 lb) over the past 7 days
4. Triglyceride 110 mgidl

49. A nurse is planning care for a client who has full thickness burns on the lower extremities. Which of the following interventions should the nurse include?

1. Provide a diet of fresh fruits and vegetables for the client.
2. Apply new gloves when alternating between wound care sites.
3. Limit visitation time for the client's children to 40 min per day.
4. Clean the equipment in the client's room once per week.

50. A nurse is teaching a client how to use a quad cane for ambulation following a right-hemispheric stroke. Which of the following client actions indicates an understanding of the teaching?

1. Client moves the cane 2 feet ahead
2. Client takes a step before advancing the cane
3. Client holds the cane with the left hand
4. Client advances the weaker leg forward first

Answer 1

1)the correct answer is option b ,that is increased temperature .graves disease is a type of autoimmune disease in which thyroid gland produce large amount of thyroid hormone. Most common form of hyperthyroidism is graves disease .Thyroid storm or thyrotoxicosis is a complication of graves disease. It is a fatal condition characterized by high fever, hyperreflexia ,severe tachycardia ,delirium, dehydration, hypertension and extreme irritability.

From the given option the sign of thyroid storm is increased temperature. So the correct answer is option ab.

2)the correct answer is option b, that is crackles in the bilateral lung base. because bibasilar crackles indicate the presence of pulmonary edema. Pulmonary edema is most dangerous combination of TPN. TPN cause fluid shift and cause pulmonary edema .The signs of pulmonary edema should report immediately .So the correct answer is option b .

3)the correct answer is option b ,that is use new gloves when alternating between wounds.because in burn patient there is high chances for infection so we should follow standard precautions. So we should change gloves when alternating the wound in burn patient .Other options are not accurate.

4) the correct answer is option c, that is hold the cane with the left hand,because for proper use of cane is that,  cane should hold with the unaffected hand. In this case the patient have right hemiparesis so the cane should hold with left hand. Other options are incorrect method.