EXAM 2 CHA1 EAQ
After reviewing the reports of a client, the nurse suspects hypofunctioning of the adrenal gland. Which findings are consistent with hypofunctioning of the adrenal gland? Select all that apply.
decreased serum sodium decreased serum cortisol increased serum calcium Hypofunctioning of the adrenal gland is manifested by increased serum calcium, decreased serum cortisol, and decreased serum sodium levels. Decreased serum potassium and decreased serum bicarbonate levels are associated with hyperfunctioning of the adrenal gland. Normal to increased serum glucose is associated with hyperfunctioning of the adrenal gland.
The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client?
kuss resp Kussmaul respirations occur in diabetic ketoacidosis (DKA) as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis) HHNS affects people with type 2 diabetes who still have insulin production; the insulin prevents the breakdown of fate into ketones. Fluid loss is common in both because an increased blood sugar ultimately leads to polyuria. Glycosuria is common in both conditions. Hyperglycemia is common in both conditions.
Which clinical manifestations in a client indicate hyperfunctional thyroid gland? Select all that apply.
weight loss Diarrhea Diarrhea and weight loss are the characteristic manifestations of a hyperfunctional thyroid gland. Anemia is seen in a client with a hypofunctional thyroid and decreased levels of thyroid hormone. Decreased appetite and distant heart sounds are symptoms of a hypofunctional thyroid gland.
A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage?
A yellow edge around nasal discharge Nasal hypophysectomy is a surgical procedure performed to treat hyperpituitarism due to pituitary gland tumors. During postoperative care and follow-up, the appearance of light-yellow at the edge of otherwise clear nasal discharge in the dressing indicates leakage of cerebrospinal fluid (CSF). This is called the "halo sign" and is indicative of a CSF leak. Dry mouth after nasal hypophysectomy is normal due to the client breathes trough their mouth due to nasal packing. Neck rigidity could be an indication of infection, such as meningitis following surgery. A fall in blood pressure upon standing is called orthostatic hypotension and is a side effect of bromocriptine.
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate?
Arterial insufficiency Clients experiencing arterial insufficiency present with lower extremities that become pale when elevated and dusky red when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny and thin with decreased hair growth and thickened nails. Clients with venous insufficiency ofter have normal-colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around the ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result to impaired flow of the lymphatic system.
What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply.
Assessing for and reporting changes in neurological status. Monitoring for constipation, weight loss, hypotension and tachycardia Providing adequate fluids within easy reach. Diabetes insipidus is a condition resulting in underproduction of antidiuretic hormone. The focus of care is on maintaining fluids and electrolytes. Oral fluids must be easily accessible at the bedside to balance urinary losses and prevent severe dehydration The nurse monitors for, and reports, changes in neurological status associated with hypernatremia and high serum osmolality. Constipation and weight loss indicate fluid volume deficit and must be reported. Hypotension and tachycardia are signs of impending shock. Massive polyuria results is dilute urine. Decreasing urine specific gravity must be reported. There is no indication that an antibiotic is required; therefore erythromycin would not be described. The primary pharmacologic treatment for diabetes insipidus, then, is replacement of antidiuretic hormone (ADH) with an exogenous vasopressin, such as desmopressin acetate (DDAVP).
Which treatment intervention should be provided to a client diagnosed with Cushing's disease?
Decrease blood glucose levels Cushing's disease affects the glucose metabolism and results in reduced glucose uptake by tissues and increased glucose levels; therefore interventions to regulate blood glucose levels should be undertaken. Hypersecretion of cortisol causes Cushing's disease; therefore interventions should be aimed at decreasing the cortisol levels. Sodium levels are elevated in hypercortisolism; therefore interventions to decrease these levels should be initiated. Measures to increase the low serum calcium levels in Cushing's disease will be beneficial to the client.
On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify?
Deep and rapid respirations Deep, rapid respirations are an adaptation to a decreased serum pH. Carbonic acid dissociates in the lungs to hydrogen ions and carbon dioxide, which helps increase the serum pH. Muscle twitching results from low serum calcium (hypocalcemia), not compensated metabolic acidosis. Mental confusion does not occur in compensated acidosis; confusion can occur in uncompensated metabolic acidosis. Tachycardia and cardiac dysrhythmias are associated with hyperthyroidism, not compensated metabolic acidosis.
When caring for a client with venous insufficiency, the nurse would implement which nursing measure?
Elevate the client's legs above heart level. Venous insufficiency occurs when vascular damage impedes the body's ability to move blood from the legs toward the heart. This causes blood to pool in the legs, where it can cause swelling, pain, and in some cases, leaking fluid in the skin or ulcers. Elevation of the legs above the level of the heart makes up of gravitational forces to drain blood through the veins toward the heart. Clients should not wear tight restrictive pants and should avoid wearing a girdle or garter, which may impede venous return. Compression stockings prevent blood pooling. Elevating the upper extremities will not decrease edema in lower extremities.
Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (25 mmol/L). Which action should the nurse take?
Encourage the client to take deep, cleansing breaths The client is in respiratory acidosis, probably caused by the depressant effects of an anesthetic or a compromised airway; deep breaths blow off CO2 and encourage coughing. Obtaining a prescription for a diuretic will not correct the respiratory acidosis and may aggravate hypokalemia if present. Having the client breathe into a rebreather bag is a treatment for respiratory alkalosis; the client is in respiratory acidosis. Obtaining a medical prescription for the administration of sodium bicarbonate is not necessary if clearing of the airway corrects the problem.
A nurse is caring for a client with Addison's disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake?
Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium Lack of mineralocorticoids (aldosterone) leads to loss of sodium ions in the urine and subsequent hyponatremia. Potassium intake is not encouraged; hyperkalemia is a problem because of insufficient mineralocorticoids. Increasing protein is needed to heal the adrenal tissue and thus cure the disease caused by idiopathic atrophy of the adrenal cortex; tissue repair of the gland is not possible. Vitamins are not directly energy-producing; nor will they help the client gain weight.
Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes?
Hyperglycemia and urine negative for ketones In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia. Ketones in the blood but not in the urine does not occur with either. In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketone, but insulin resistance leads to hyperglycemia and diabetes mellitus. Glucose in the urine but not hyperglycemia is impossible, if glycosuria is present, the level of glucose in blood first must exceed the renal threshold of 160 to 180 mg/dl (8.9 to 10mmol/L). Blood and urine positive for both glucose and ketones is expected in uncontrolled type 1 diabetes
A nurse is caring for a client admitted to the hospital with a diagnosis of Addison's disease. The nurse should assess the client for what signs related to this disorder?
Hypoglycemia and hypotension Adrenocortical insufficiency causes decreased glucocorticoids, resulting in hypoglycemia; also, it causes decreased aldosterone resulting in fluid excretion that leads to hypotension. Although diarrhea can occur initially with steroid replacement, it should subside; pyrexia will occur only if there is a concomitant infection. Edema and hypertension are not related to Addison disease; they are associated with Cushing disease, because of excessive cortisol and aldosterone, resulting in fluid and sodium retention. Moon face and hirsutism are related to Cushing disease, not Addison disease; moon face is caused by adipose tissue deposition, and hirsutism is caused by excessive androgen secretion.
The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?
Inactivity DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT, secondary to inactivity. Aerobic exercise is not a risk factor for DVT.
A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply.
Increased heart rate increased temp Thyroid storm is severe hyperthyroidism; excessive amounts of thyroxine increases the metabolic rate, thereby causing an increased heart rate (tachycardia). Because of the increased metabolic rate associated with thyroid storm, body temperature will increase. Because of the increased metabolic rate associated with thyroid storm, the respiratory rate increases (tachypnea) to meet the body's oxygen needs. Pulse deficit, the difference between apical and peripheral pulse rates, is not indicative of thyroid storm. The blood pressure will increase to meet the oxygen demand caused by the increased metabolic rate during thyroid storm.
An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should the nurse include in the teaching plan? Select all that apply.
Insulin therapy Adherence to the treatment regimen Blood glucose monitoring Because clients with type 1 diabetes have little or no endogenous insulin, they must take insulin. Blood glucose monitoring is an important aspect of therapy because it aids evaluation of the effectiveness of diabetic control. Dietary control and exercise reduce the amount of exogenous insulin needed. Although adhering to the diabetic regimen is difficult, especially for adolescents who need to identify with their peers, its importance in promoting euglycemia should be discussed. Although infection increases insulin requirements, prophylactic antibiotics are not needed. Oral hypoglycemics are ineffective in stimulating insulin secretion in clients with type 1 diabetes.
A nurse is teaching the parents of an 8-year-old child who is taking a high dose of oral prednisone for asthma. What critical information about prednisone will be included?
It should be stopped gradually. Gradual weaning from prednisone is necessary to prevent adrenal insufficiency or adrenal crisis. Prednisone depresses the immune system, thereby increasing susceptibility to infection. The drug usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect.
An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?
Metabolic acidosis A low pH and low bicarbonate level are consistent with metabolic acidosis.
A nurse is planning an evening snack for a child receiving NPH insulin. What is the reason for this nursing action?
Nourishment helps counteract late insulin activity. A bedtime snack is needed for the evening. NPH insulin is intermediate-acting insulin, which peaks 4 to 12 hours later and lasts for 18 to 24 hours. Protein and carbohydrate ingestion before sleep prevents hypoglycemia during the night when the NPH is still active. The snack is important for diet-insulin balance during the night, not encouragement. There is no data to indicate that extra calories are needed; a bedtime snack is routinely provided to help cover intermediate-acting insulin during sleep. The snack must contain protein-rich foods, not simple carbohydrates, to help cover the intermediate-acting insulin during sleep.
A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply
Pain at ulcer site Lack of hair Diminished pedal pulses Thickened toenails Prolonged lack of oxygen to hair follicles results in hair loss. Prolonged lack of oxygen to the toes results in thickened toenails. Arterial ulcers are painful because of the interruption of blood supply to peripheral tissues. Inadequate arterial perfusion results in diminished volume of blood flow to the lower extremities. Brown skin discoloration is characteristic of venous ulcers
A client is scheduled for an adrenalectomy. What does the nurse expect that the plan of care will include?
Parenteral corticosteroids Steroid therapy usually is given intravenously or intramuscularly preoperatively and continues intraoperatively to prepare for the acute adrenal insufficiency that follows surgery. The diet must supply ample protein and potassium. A 24- hour urine specimen in unnecessary. Corticosteroids must be administered preoperatively to prevent adrenal insufficiency during surgery, so withholding all medications for 48 hours before surgery is contraindicated.
Which does the nurse state is a secondary cause of adrenal insufficiency?
Pituitary tumors Adrenal insufficiency is also called Addison's disease. Secondary causes of adrenal insufficiency include pituitary tumors. Primary causes, which are responsible for adrenal insufficiency, include hemorrhage, tuberculosis, and metastatic cancer.
In anticipation of a client returning to their room following a subtotal thyroidectomy, what intervention would be highest priority for the nurse to perform?
Place a tracheostomy set at the bedside. Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema around the operative site also may cause an airway obstruction. Although not common, airway obstruction after thyroid surgery is an emergent situation. Oxygen, suction equipment, and a tracheostomy tray should be readily available in the client's room A patent airway takes priority over incision inspection. Speaking is important to determine the status of the laryngeal nerve. The semi-fowler position is indicated to maximize respiratory excursion. TESTING TIP- If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action.
A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, what will the nurse include in the teaching?
Report palpations, nervousness, tremors, or loss of weight that may indicate and overdose of thyroid hormone. Excessive thyroid hormone replacement may lead to signs and symptoms of hyperthyroidism. Iodine may be administered before, not after, surgery. Thyroid hormone replacement is required for life. Propylthiouracil blocks thyroid hormone synthesis; this often is administered before, not after, surgery.
The nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which finding in the client is consistent with the diagnosis?
Retention of water SIADH is manifested in the form of retention of free water. This is because of excessive secretion of vasopressin causing reabsorption of water in renal tubules. There is hyponatremia and dilution of serum sodium in SIADH. Decreased vasopressin is seen in diabetes insipidus. Generally pedal (dependent) edema is not seen in SIADH despite water retention.
A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply.
Sleep distrubance Truncal obesity thin arms and legs Truncal obesity is a key feature of Cushing syndrome. Sleep disturbance is caused by the altered diurnal secretion of cortisol. Thin arm and legs are caused by protein catabolism, which causes muscle wasting. Polyuria is associated with diabetes mellitus and primary aldosteronism, not Cushing syndrome. Obesity is caused by the overproduction of adrenal cortisol hormone associated with Cushing syndrome. Hypertension, not hypotension, is associated with Cushing syndrome because of the sodium and water retention.
A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experiencing a sudden fall in the blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing?
Somogyi effect The Somogyi effect is a response to hypoglycemia induced by too much insulin; the body responds to the hypoglycemia by counterregulatory hormones stimulating lipolysis, gluconeogenesis, and glycogenolysis, resulting in rebound hyperglycemia. The Dawn phenomenon is hyperglycemia that is present on awakening in the morning because the release of counterregulatory hormones in the predawn hours; it is thought that growth hormone or cortisol is related to this phenomenon. Diabetic ketoacidosis (diabetic coma) is a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. Hyperosmolar nonketotic syndrome occurs in clients with type 2 diabetes. It is a condition in which the client produces enough insulin to prevent diabetic ketoacidosis but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply.
The client should obtain a finger stick glucose reading before each meal. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan should include sick day rules. All diabetic clients, regardless of type, should check finger stick blood sugars before each meal and snack. Antidiabetic medications can cause hypoglycemia; therefore, the client needs to be instructed on the symptoms of hypoglycemia. All diabetic clients need to be educated on sick day ruled. All diabetic clients should follow the American Diabetes Association diet.
To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices?
They help with venous blood return to the heart. Deep vein thrombosis (DVT) is a potential complication of any surgery lasting longer than 30 minutes. The purpose of the pneumatic compression devices is to increase venous return. Clients often complain about pneumatic compression devices being hot and itchy. In additional to the pneumatic compression devices, a mechanical form of DVT prophylaxis, pharmaceutical prophylaxis is often required. Pneumatic compression devices are continued until the client is up ambulating frequently throughout the day.
A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client?
Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3) A decreased TSH array together with an elevated T3 level may indicate hyperthyroidism. X-ray results will not indicate thyroid disease, and elevation of T4 level might indicate hyperthyroidism. However, this may be a false reading because of the prescence of thyroid-binding globulin (TBG) and is inadequate for diagnosis when used alone. PO2 is not specific to thyroid disease, and the thyroglobulin level is most useful to monitor for recurrence of thyroid carcinoma or response to therapy. The results with the SMA are not specific to thyroid disease; the protein-bound iodine test in not definitive because it is influenced by the intake of exogenous iodine.
