Nursing Fundamentals NCLEX Questions

A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply. 1. Instill isotonic eyedrops as necessary. 2. Provide several small, well-balanced meals. 3. Provide regular rest periods. 4. Keep the environment warm. 5. Encourage frequent visitors. 6. Weigh the client daily.

1, 2, 3, 6 Rationale: hyperthyroidism results in increased appetite, which can be satisfied by frequent, small, well-balanced meals. The nurse would provide the client with rest periods to reduce metabolic demands. The client would be weighed daily to check for weight loss, a possible consequence of hyperthyroidism. Because my metabolism is increased and hyperthyroidism, heat intolerance and excitability result.

A client has a tumor of the posterior pituitary gland. In nurse planning care would include which nursing interventions? Select all that apply. 1. Weigh the client daily. 2. Restrict fluids. 3. Measure urine specific gravity. 4. Encourage intake of coffee or tea. 5. Monitor intake and output.

1, 3, 5 Decreased antidiuretic hormone results in reduced ability to concentrate urine, resulting in an excessive urination, thirst, and fluid intake.

A neonatal nurse is assessing a 2-week-old's pain level following open heart surgery. To assess the pain level using an age-appropriate scale, which scales would be appropriate? Select all that apply. 1. Numerical 0-10 scale 2. FLACC scale 3. Wong-Baker FACES Pain Rating Scale 4. Visual Analog Scale 5. NIPS

2, 5 Rationale: Only Face, Legs, Activity, Cry, Consolability (FLACC) scale and Neonatal Infant Pain Scale (NIPS) are behavioral scales appropriate for a neonate.