The nurse is caring for a school-age child with hyperthyroidism (Graves disease). Which clinical manifestations should the nurse monitor that may indicate a thyroid storm? (Select all that apply.)
a. Constipation
b. Hypotension
c. Hyperthermia
d. Tachycardia
e. Vomiting
ANS: C, D, E
A child with a thyroid storm will have severe irritability and restlessness, vomiting, diarrhea, hyperthermia, hypertension, severe tachycardia, and prostration.
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A nurse is providing care for a female patient who is Hispanic
The care team is discussing the patient's nutritional status and one of the nurse's colleagues states, "I suppose we should try to get her some tacos or burritos since that's what she's probably used to." How should the nurse best interpret the colleague's statement? A) The colleague may have stereotypical views of Hispanics. B) The colleague is exemplifying the process of acculturation. C) The colleague is aware of the dietary characteristics of Hispanic culture. D) The colleague may harbor resentment against Hispanics.
The parents of a 5-year-old bring their son to the emergency department because of significant eyelid edema. The mother states, "He scratched himself near his eye a couple of days ago while playing outside in the yard"
The nurse suspects periorbital cellulitis based on which of the following? A) Evidence of discharge B) Reddened conjunctiva C) Purplish discoloration of eyelid D) Altered visual acuity
Which of the following interventions is used to prevent falls in a health care agency?
A) Display the phone number for the nurses' station. B) Read label directions. C) Keep the environment tidy. D) Keep electrical cords under the bed.
The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis?
1. Measles, mumps, and rubella (MMR) 2. Haemophilus influenzae type B (HIB) 3. Hepatitis B 4. Polio