Endocrinology Exam

Correct Answer: D

Rationale: The correct answer is the pulse rate of 115 beats/min. A rapid pulse rate is a sign of compensatory mechanisms in response to dehydration, indicating that the body is trying to deliver oxygen more efficiently. Oxygen therapy may be needed to support the increased oxygen demand. Tenting of skin on the back of the hand is a classic sign of dehydration due to decreased skin turgor. Increased urine osmolarity and weight loss are also indicators of dehydration, but they do not directly suggest a need for oxygen therapy.

Correct Answer: D

Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.

Correct Answer: C

Rationale: In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.

Correct Answer: D

Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.

Correct Answer: D

Rationale: The correct answer is 'My rings seem to be tighter this week.' This assessment finding indicates possible fluid retention, which can be a sign of fluid or electrolyte imbalance in an older adult. Choices A, B, and C do not specifically point towards fluid or electrolyte imbalance. Feeling cold, increased urination with coffee consumption, and feeling thirsty in the summer are not direct indicators of fluid or electrolyte imbalance in this context.