Exam 3 DA & Book Practice

Which assessment changes should the nurse anticipate in an adult patient with increased secretion of growth-stimulating hormone (GSH)? Select all that apply. Increased bone density Weight loss Increased risk of fractures Menstrual irregularities Coarse facial features

Increased bone density Menstrual irregularities Coarse facial features

Which laboratory data should the nurse anticipate when providing care for a client who is experiencing hypercortisolism? Decreased cortisol level Increased glucose level Increased potassium level Increased serum sodium level

Increased glucose level

Which patient is most likely to have Conn's syndrome? Patient A: Sodium 140 Patient B: Potassium 5.7 Patient C: BP 116/60 Patient D: Sodium 152

Patient D: Sodium 152 (Conn's syndrome -> Hyperaldosteronismn -> Aldosterone responsible for sodium & water reabsorption & potassium excretion -> Low potassium, high sodium (normal Na+ = 135 to 145, normal K+ = 2.5 to 4.5))

The nurse notes that a client with a thyroid gland removal 2 days ago is experiencing a prolonged PR interval on the cardiac monitor. What lab should the nurse assess next? Sodium Potassium Chloride Calcium

Calcium

The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH), who has been admitted with headache and confusion after a decrease in the serum sodium level. What is the cause of the neurological symptoms? Anorexia Fluid overload Decreased urine output Increased intracranial pressure

Increased intracranial pressure

Regardless of the type of diabetes insipidus, what is the primary pathophysiological mechanism? Abnormal glycemic control Decreased secretion of antidiuretic hormone Increased plaque formation Abnormal demyelination

Decreased secretion of antidiuretic hormone

eleasing gland of thyroid-stimulating hormone (TSH) HYPOTHALAMUS ANTERIOR PITUITARY POSTERIOR PITUITARY

ANTERIOR PITUITARY (TSH is released from the anterior pituitary, targeting the thyroid glands to release T3 and T4.)

DI - Urine-Specific Gravity 1.000 1.030

1.000 (Urine-specific gravity is less than 1.005 in patients who have DI. The urine is dilute from the loss of water.)

The nurse is reviewing the sodium level of several patients. Which laboratory result indicates hyperaldosteronism? 150 mg/dL 130 mg/dL 142 mg/dL 128 mg/dL

150 mg/dL (Hyperaldosteronism -> Hypokalemia & Hypernatremia; Na+ = 135 to 145)

The nurse is caring for a patient after a transsphenoidal hypophysectomy. Which assessment changes are most concerning? Heart rate is increased. Pulse is full and bounding. Blood pressure is increased. Serum osmolality is decreased.

Heart rate is increased.

A patient with a pheochromocytoma has undergone unilateral adrenalectomy. Which condition should the nurse monitor in the patient postoperatively? Hyperhidrosis Hypermetabolism Hypovolemic shock Cardiac arrhythmias

Hypovolemic shock

DI - Thirst INCREASED DECREASED

INCREASED (DI results in intravascular dehydration, which activates the thirst mechanism.)

Releasing gland of testosterone HYPOTHALAMUS TESTES OVARIES

TESTES (Testosterone is released from the testes, targeting male reproductive organs to promote maturation of sex organs, sperm production, and development of secondary sex characters.)

The nurse is teaching a patient about precautions to follow for application of silver sulfadiazine. Which statements made by the patient indicate effective teaching? Select all that apply. "I should avoid applying the medication to my face." "I should apply it one-fourth inch thick with roll gauze." "I should apply the cream around the eyes." "I should apply the cream one-sixteenth inch thick and leave it open to air." "I should apply a thin layer with nonadherent gauze and outer roll gauze."

"I should avoid applying the medication to my face." "I should apply it one-fourth inch thick with roll gauze."

A patient with a lack of growth hormone says to the nurse, "I'm already full grown, I don't see why it's important." How should the nurse respond? "You are lucky that you don't have dwarfism." "A lack of this hormone puts you at risk for osteoporosis." "Your bones could become shorter with this hormone loss." "Your bones will increase density from a lack of this hormone."

"A lack of this hormone puts you at risk for osteoporosis."

The nurse is providing discharge instructions to a patient and his family after a diagnosis of diabetes insipidus (DI). Which instructions should be included? Select all that apply. "Check body weight daily at the same time and on the same scale." "Report weight changes of more than 5 pounds per day." "Drink plenty of fluids." "Maintain adequate mouth care." "Know that overuse of desmopressin may lead to dehydration."

"Check body weight daily at the same time and on the same scale." "Drink plenty of fluids." "Maintain adequate mouth care."

.The nurse is providing discharge instructions to a patient and his family after a diagnosis of diabetes insipidus (DI). Which instructions should be included? Select all that apply. "Check body weight daily at the same time and on the same scale." "Report weight changes of more than 5 pounds per day." "Drink plenty of fluids." "Maintain adequate mouth care." "Know that overuse of desmopressin may lead to dehydration."

"Check body weight daily at the same time and on the same scale." "Drink plenty of fluids." "Maintain adequate mouth care." "Know that overuse of desmopressin may lead to dehydration."

Which assessment finding is most likely to occur in a patient with diabetes insipidus (DI)? Hypertension Urine-specific gravity 1.005 Serum sodium 140 mg/dL Urine osmolality 190 mOsm/kg

Urine osmolality 190 mOsm/kg

A patient has a superficial partial-thickness burn. Which is accurate in terms of the healing period of the burn? 3 to 7 days with no scarring 7 to 14 days with no scarring 3 to 6 weeks with some scarring Will not heal without excision and grafting

7 to 14 days with no scarring

Which patient is at the greatest risk of developing primary adrenal insufficiency? A 16-year-old female A 47-year-old female A 53-year-old male A 79-year-old male

A 47-year-old female

A patient with osteoporosis and a recent fracture asks the nurse what the provider meant by saying it could be caused by hormone deficiency. How should the nurse reply? "Growth hormone, when low, can decrease bone density." "Luteinizing hormone is important in strengthening the bones." "Follicle-stimulating hormone allows for the stimulation of strong bone formation." "Adrenocorticotropic hormone acts on the bones, making them stronger."

"Growth hormone, when low, can decrease bone density." (Rationale: Osteoporosis may result with decreased secretion of growth hormone. This causes decreased bone density.)

Which statement made by a client diagnosed with adrenal insufficiency requires further education by the nurse? "I need to take my oral hormone replacement every day." "I no longer need to worry about symptoms of my disorder because it cannot recur." "I will purchase and wear a medical alert bracelet." "I will notify my doctor if I begin to gain weight."

"I no longer need to worry about symptoms of my disorder because it cannot recur."

The nurse is teaching a patient with partial thickness burns about the care considerations for managing the burns. Which statement made by the patient indicates a need for further teaching? "I should not pop the blisters." "I should change the dressing at least once every two days." "I should wash the area with warm water if a blister is broken." "I should apply a Bacitracin ointment and cover with a nonadherent bandage."

"I should change the dressing at least once every two days."

patient with hypoparathyroidism has a positive Chvostek sign. Which statement made by the patient indicates a need for better understanding of the condition? "I should eat foods rich in calcium." "I should maintain adequate hydration." "I should eat foods rich in phosphorus." "I should be knowledgeable about signs of hypocalcemia."

"I should eat foods rich in phosphorus."

Releasing gland of glucagon PANCREAS LIVER HYPOTHALAMUS

(Glucagon is released from the pancreas, targeting the liver and muscles to promote glycogenolysis which increases blood glucose levels.)

The nurse is caring for a post-operative client who had his thyroid gland removed. What should the nurse have placed at the bedside? A glass of water without a straw An emergency tracheostomy tray Throat lozenges An emesis basin

An emergency tracheostomy tray

Releasing gland of cortisol ANTERIOR PITUITARY ADRENAL CORTEX ADRENAL MEDULLA

ADRENAL CORTEX (Cortisol (glucocorticoids) are released from the adrenal cortex, targeting the liver, cells, and bone marrow. It causes the liver to increase blood glucose levels. In the cells it decreases glucose use, promotes protein catabolism, and promotes fat synthesis. In the bone marrow it suppresses inflammatory processes.)

Releasing gland of follicle-stimulating hormone (FSH) ADRENAL CORTEX ADRENAL MEDULLA ANTERIOR PITUITARY

ANTERIOR PITUITARY (FSH is released from the anterior pituitary, targeting the ovaries to stimulate maturation of ovarian follicles, ovulation, and estrogen secretion.)

The female patient with adrenal cortex hyperfunction tells the nurse, "My body has changed so much since I was diagnosed with this." What changes might the patient be referring to? Select all that apply. Abnormal fat distribution Male sexual characteristics Increasing menstruation Breast atrophy Deepening voice

Abnormal fat distribution Male sexual characteristics Increasing menstruation Breast atrophy Deepening voice

The nurse is caring for a patient in the emergency department with acute symptoms of diabetes insipidus including urine output of 450 mL per hour and a mean arterial pressure of 65 mm Hg. What is the priority action? Administer prescribed IV fluid. Monitor the patient for hypoglycemia during IV administration. Monitor the patient for dehydration. Ensure serum sodium level increases by 0.5 mmol/L every hour.

Administer prescribed IV fluid.

Given this laboratory report, what condition does the patient most likely have? Cortisol: 2 mg/dL Glucose: 68 mg/dL Sodium: 132 mEq/L Potassium: 5.4 mEq/L Adrenal insufficiency Hyperaldosteronism Pheochromocytoma Syndrome of inappropriate antidiuretic hormone

Adrenal Insufficiency

When a client is experiencing a lack of cortisol, which glands could be the cause? Select all that apply. Adrenal gland Parathyroid gland Hypothalamus Pituitary gland Thyroid gland

Adrenal gland Hypothalamus Pituitary gland

A nurse is comparing the hormones of the pituitary gland in preparation for care of a patient undergoing a posterior lobe removal. Which hormone is secreted through the posterior lobe of the pituitary gland? Antidiuretic hormone (ADH) Follicle-stimulating hormone (FSH) Growth-stimulating hormone (GSH) Adrenocorticotropic hormone (ACTH)

Antidiuretic hormone (ADH) (Rationale: The posterior lobe of the pituitary is responsible for the hormonal action of ADH. The hormone controls water retention by the kidneys. It also moderates vasoconstricton.)

The nurse is caring for a patient postoperatively after undergoing surgical removal of the parathyroid tissue. What action is the priority? Assess plasma calcium levels. Administer thyroid replacement therapy twice daily for a month. Ensure the patient's room is cool. Monitor the patient for signs of lowered cholesterol levels.

Assess plasma calcium levels.

The nurse is caring for a client in the intensive care unit who is 36 hours post-deep partial-thickness burn to the left lower extremity. Which nursing interventions would be in place to decrease the development of compartment syndrome? Monitor pulses in both burned and unburned extremities every 8 hours. Assess pulses hourly in burned and unburned extremities. Monitor sodium and potassium levels every 4 hours. Maintain the head of the client's bed at 45 degrees.

Assess pulses hourly in burned and unburned extremities.

Which topical medication is the best for use on the face and around the eyes? Bacitracin Mafenide acetate Silver sulfadiazine Mepilex

Bacitracin

Which type of burn injury causes coagulation of proteins and a full-thickness injury due to the release of hydrogen ions that reduces pH to less than 0? Gasoline Wet cement Bathroom cleaners Heavy industrial cleaners

Bathroom cleaners

A patient with hyperthyroidism is experiencing palpitations. Which medication is most effective to treat this? Beta-adrenergic blocking agents Antithyroid medications Iodine preparations Glucocorticoids

Beta-adrenergic blocking agents

A client diagnosed with pheochromocytoma is post-operative following an adrenalectomy. What clinical data should the nurse monitor following surgery? Select all that apply. Red blood cell level Blood pressure Heart rate Blood glucose level Blood potassium level

Blood pressure Blood glucose level Blood potassium level

A patient with syndrome of inappropriate antidiuretic hormone (SIADH) is hospitalized. Which presenting symptoms should the nurse anticipate? Thirst is increased. Pulse is weak and accelerated. Blood urea nitrogen is decreased. Urine specific gravity is decreased.

Blood urea nitrogen is decreased.

When formulating the plan of care for Mrs. DeToro, which psychosocial nursing diagnosis is a priority? Fluid volume deficit Risk for unstable blood glucose Risk for decreased cardiac output Body image disturbance

Body image disturbance (While all of these nursing diagnoses are appropriate for a patient who is experiencing an adrenal crisis, the priority psychosocial nursing diagnosis is disturbed body image due to the hyperpigmentation of the skin)

The nurse discovers each of these findings during the initial focused assessment. Which is a characteristic of syndrome of inappropriate antidiuretic hormone (SIADH) disorder? Polyuria Hypernatremia Hypotension Bounding pulse

Bounding pulse

A patient presents to the emergency department with the symptoms presented in the image. What additional assessments should the nurse perform? Bradycardia, hypothermia, and weight gain Heat intolerance, nervousness, and fatigue Muscle twitching, hypotension, and cramping Muscle weakness, low back pain, and constipation

Bradycardia, hypothermia, and weight gain

The nurse is teaching about types of burns. Which statement is true about a chemical burn? Burns caused by gasoline Burns caused while cooking Burns caused by ionizing radiation Burns caused by overheard power lines

Burns caused by gasoline

A patient with hyperaldosteronism has a potassium of 2.8 mEq/L. Which complication should the nurse monitor for? Acute stroke Myocardial infarction Cardiac dysrhythmias Paroxysmal hypertension

Cardiac dysrhythmias

The nurse is caring for a client with superficial burns on greater than 20% total body surface area. What body systems would the nurse monitor? Select all that apply. Cardiovascular Gastrointestinal Nervous Renal Immunologic

Cardiovascular Gastrointestinal Renal Immunologic

The nursing student asks the nurse how central diabetes insipidus (DI) is different from nephrogenic DI. How should the nurse respond? Central DI occurs because the kidneys are resistant to ADH. Central DI is caused by decreased secretion of ADH. Central DI is observed in patients with chronic renal insufficiency. Central DI occurs when the kidneys are unable to concentrate urine.

Central DI is caused by decreased secretion of ADH.

The nurse is caring for a client with an elevated thyroid stimulating hormone (TSH) level. Which assessments are consistent with this finding? Select all that apply. Constipation Weight gain Edema Tachycardia Restlessness and anxiety

Constipation Weight gain Edema (Rationale: The diagnosis of hypothyroidism is confirmed through analysis of laboratory data, including T3, T4, and TSH. If the etiology is primary hypothyroidism, the TSH level is elevated as a result of the feedback system to the hypothalamus and anterior pituitary gland caused by low circulating levels of thyroid hormones (T3 and T4). The hypometabolic state is characterized by decreased energy, increased sleep, fatigue, weight gain, decreased appetite, and susceptibility to cold temperatures. Decreased gastrointestinal activity results in constipation and abdominal distention.)

The nursing student is observing in the burn unit. The student would expect to see which infection control measures implemented in the burn unit? Select all that apply. Contact precautions for all client interactions Use of antibiotic-coated intravenous and central line catheters Use of betadine hand scrub by nursing staff before and after caring for clients Changing Foley catheters every 72 hours Use of disposable equipment such as blood pressure cuffs and stethoscopes

Contact precautions for all client interactions Use of antibiotic-coated intravenous and central line catheters Use of disposable equipment such as blood pressure cuffs and stethoscopes

Blood pressure HYPERTENSION HYPOTENSION

HYPOTENSION (With polyuria and dehydration, blood pressure will decrease.)

The nurse is assessing a client diagnosed with adrenal cortical insufficiency. What clinical manifestations will the nurse expect to observe? Select all that apply. Weight gain Increased secretion of corticotropin-releasing hormone and adrenocorticotropic hormone Hypertension Increased secretion of melanocyte-stimulating hormone Darkened, bronzed hyperpigmentation

Increased secretion of corticotropin-releasing hormone and adrenocorticotropic hormone Increased secretion of melanocyte-stimulating hormone Darkened, bronzed hyperpigmentation

The nurse is caring for a patient with adrenal insufficiency. Which *assessment changes* can be anticipated? Increased body weight Decreased blood glucose Increased blood pressure Increased serum potassium

Increased serum potassium (Blood glucose is increased w/ adrenal insufficiency????)

A nurse reviews a radiological report for a patient that says the adrenal gland is enlarged. What situation can cause this finding to occur? Infectious processes Autoimmune destruction Insufficient secretion Hypersecretion

Infectious processes

Which clinical manifestations should the nurse anticipate when providing care to a client diagnosed with Cushing's disease? Select all that apply. Moon face Hypotension Buffalo hump Hypoglycemia Hypotension

Moon face Buffalo hump

The functioning of the endocrine system works on what type of system? Negative feedback system Positive feedback system Alternating negative and positive feedback system Closed loop system

Negative feedback system

Which is most appropriate for the nurse to assess when caring for a patient diagnosed with hyperpituitarism due to increased secretion of adrenocorticotropic hormone (ACTH)? Select all that apply. Pain caused by compression of peripheral nerves Neurological assessment and vision Urine intake and output Daily weight Changes in the size of the hands

Neurological assessment and vision Urine intake and output Daily weight (Not Pain caused by compression of peripheral nerves or Changes in the size of the hands bc that would be GH, not ACTH)

The nurse discovers a positive Chvostek and Trousseau sign in a client recovering from radiation to the neck for thyroid cancer. What should be the nurses next action? Evaluate the blood pressure Notify the provider Assess the serum calcium level Evaluate the urine calcium level

Notify the provider (Rationale: Two specific assessments observed in hypocalcemia are Chvostek sign (Fig. 43.8A) and Trousseau sign (Fig. 43.8B) and are associated with an increased risk of tetany that can result in laryngospasm and airway compromise (see management of tetany above)

Which clinical manifestations present in a patient most likely indicates compartment syndrome? Select all that apply. Numbness Red-colored urine Diminishing pulse Complaints of pain with flexion Urine output less than 1 mL/kg/hr

Numbness Diminishing pulse Complaints of pain with flexion

A patient is placed on intravenous oxytocin. What teaching should the nurse provide before beginning the medication? Oxytocin will increase water reabsorption. Oxytocin will stimulate sperm production. Oxytocin will facilitate bone and tissue growth. Oxytocin will stimulate uterine contractions in labor.

Oxytocin will stimulate uterine contractions in labor. (Rationale: Oxytocin is secreted by the posterior pituitary gland. It stimulates uterine contractions in labor. It also stimulates milk ejection.)

Releasing gland of insulin PANCREAS LIVER HYPOTHALAMUS

PANCREAS (Insulin is release from the pancreas, targeting the cells of the body to lower blood glucose levels by moving glucose into the cells.)

Releasing gland of parathyroid hormone (PTH) PARATHYROID ANTERIOR PITUITARY HYPOTHALAMUS

PARATHYROID (PTH is released from the parathyroid gland targeting bones, kidney, and intestines to increase osteoclastic activity, reabsorption of calcium, and gastrointestinal reabsorption of calcium.)

The client is experiencing problems with reabsorption of calcium. Which endocrine gland requires evaluation? Parathyroid gland Pancreas Hypothalamus Anterior pituitary

Parathyroid gland

The nurse is assessing the health record of four different patients. Which patient's medical report indicates a risk for laryngospasm? Patient A: 4.5 mg/dL Patient B: 8.3 mg/dL Patient C: 9 mg/dL Patient D: 10 mg/dL

Patient A

What are the primary clinical manifestations seen in clients with diabetes insipidus? Select all that apply. Polyuria Nausea and vomiting Nocturia Fatigue Polydipsia

Polyuria Nocturia Fatigue Polydipsia (Rationale: The clinical presentation of the patient with DI is dependent on the significance of water loss. Polyuria, polydipsia, and nocturia are the primary clinical manifestations seen in patients with DI. The excessive loss of water leads to hemoconcentration that is observed with elevations in serum sodium and hematocrit. The patient may present with hypotension and tachycardia secondary to hypovolemia. Other signs of fluid volume deficit including thirst, skin tenting, and fatigue may also be observed.)

The patient presents to the emergency department with 1-week symptoms of polyuria, polydipsia, hypernatremia, and tachycardia. The patient has an elevate serum osmolality. A malfunction in which area of the brain is most likely causing these symptoms? Hypothalamus Anterior lobe of the pituitary Posterior pituitary gland Sella turcica

Posterior pituitary gland

The nurse caring for a burn client is monitoring the lab values of what two electrolytes most closely during the burn shock phase? Potassium and sodium Chloride and magnesium Calcium and potassium Sodium and chloride

Potassium and sodium

The patient with adrenal sufficiency has an irregular pulse. What should the nurse evaluate next? Blood pressure Potassium level Pulse oximeter reading Sodium level

Potassium level (may be associated w/ hyperkalemia

The nurse is assessing this patient, finding this skin pigmentation abnormality. What condition does the patient have? Secondary adrenal insufficiency Primary adrenal insufficiency Primary hyperaldosteronism Primary hypercortisolism

Primary adrenal insufficiency

What is it referred to when an endocrine gland itself causes the hypersecretion or hyposecretion of a hormone? Primary disorder Secondary disorder Tertiary disorder Organ disorder

Primary disorder

Which statement in the electronic record best describes exophthalmos? Protrusion of the eyeballs Enlargement of the thyroid gland Generalized nonpitting edema Presence of coarse, dry skin

Protrusion of the eyeballs

A nurse recognizes signs of panhypopituitarism in the patient. The failure of which gland causes this condition? Reduced secretion of all hormones from the hypothalamus Reduced secretion of a hormone from the anterior pituitary gland Reduced secretion of a hormone from the hypothalamus Reduced secretion of thyroid hormones

Reduced secretion of a hormone from the hypothalamus (Panhypopituitarism is caused by reduced secretion of all hormones from hypothalamus, whereas just hypopituitarism is reduced secretion from anterior pituitary gland)

The healthcare team is caring for patients with burns in a mass casualty scene. Which method used by the healthcare team is most appropriate to determine the total body surface area (TBSA) percentage of burns of different patients in this situation? Rule of nine Rule of palm Parkland method Lund and Browder method

Rule of palm

Which is true regarding the pituitary gland? Select all that apply. The pituitary gland is located in the sella turcica. The anterior pituitary gland secretes prolactin. The posterior pituitary gland synthesizes oxytocin. The posterior pituitary gland is responsible for the growth-stimulating hormone (GSH). The anterior lobe of the pituitary is called adenohypophysis.

The pituitary gland is located in the sella turcica. The anterior pituitary gland secretes prolactin. The anterior lobe of the pituitary is called adenohypophysis (Rationale A: The pituitary gland is located in the sella turcica, a depression of the sphenoid bone.Rationale B: The anterior pituitary gland secretes the hormone prolactin, which stimulates the mammary glands for milk production.Rationale E: The anterior lobe of the pituitary gland is called adenohypophysis while the posterior lobe is called neurohypophysis.)

The nurse is performing the assessment on the neck. What gland is the nurse assessing for size and shape? Pituitary gland Adrenal glands Parathyroid glands Thyroid gland

Thyroid gland

Susan has a burn from hot oil. It is affecting the epidermis and extends into the deeper portions or bottom layers of the dermis.Drag and drop the term the nurse should use to document this. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

deep partial-thickness (A deep partial-thickness burn involves the epidermis and extends into the deeper portions or bottom layers of the dermis.)

Joseph has a burn that affects the epidermis, dermis, and portions of the subcutaneous tissue from a cooking injury. His nurse is assessing his wound.Drag and drop the classification of this burn. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

full thickness (A full thickness burn will involve damage to the epidermis, dermis, and portions of the subcutaneous tissues.)

The nurse is working in the ED and sees Vivian, a patient in triage who was involved in a fire. Vivian has no burns to the skin, but is speaking hoarsely and has singed eyebrows.Drag and drop the nurse's priority assessment. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

immediate respiratory assessment (The nurse should perform an immediate assessment of the patient to evaluate respiratory rate, effort, breath sounds, presence of carbon (soot) in the sputum, oxygen saturation, confusion, and agitation.)

The nurse is reviewing the lab work for Carlos. He was admitted 12 hours ago with a diagnosis of deep partial thickness burn. Drag and drop the decreased serum lab finding. Drag and drop the decreased serum lab finding. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

sodium level (It is expected that both the potassium and sodium levels to be decreased due to the fluid shift that occurs after the initial burn. Potassium and sodium begin to leak out of the intravascular space with this fluid shift.)

The nurse is inspecting Julia's burn. It includes the epidermis and the superficial or minimal layers of the dermis.Drag and drop the classification of this burn. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

superficial partial-thickness (A superficial partial thickness only involves damage from the epidermis through the bottom layer of the dermis.)

The nurse is caring for a patient who has had their adrenal gland removed. What hormone imbalance will be experienced? Hypoaldosteronism Hyperthyroidism Hypoparathyroidism Hyperpituitarism

Hypoaldosteronism (Rationale: Aldosterone, glucocorticoids, and catecholamines are secreted by the adrenal gland.)

The nurse is assessing four patients with endocrine abnormalities. Which patient is most at risk for renal stones? Patient A: High TSH Patient B: High T3 & T4 Patient C: Low Calcium Patient D: High Calcium

Patient D: High Calcium

The nurse is discussing instructions regarding proper nutrition with a patient that has hyperparathyroidism. Which statements made by the patient indicate a need for further discussion? Select all that apply. "I will avoid rhubarb in my diet." "I will avoid stewed figs in my diet." "I will include soy products in my diet." "I will exclude collard greens in my diet." "I will include vitamin D-fortified orange juice in my diet."

"I will avoid rhubarb in my diet." "I will avoid stewed figs in my diet." "I will exclude collard greens in my diet.".

A nurse is teaching about direct measurements of plasma catecholamines in patients with a pheochromocytoma. Which statement indicates the need for further teaching? "I will place the patient in a supine position for 30 minutes prior to the test." "I will place small IV catheters about 30 minutes prior to the actual collection of the blood samples." "I will collect urine samples for 12 hours." "I will ensure that the patient does not eat a banana."

"I will collect urine samples for 12 hours."

The nurse is teaching a patient with hyperparathyroidism about treatment strategies. Which statement by the patient indicates the need for further teaching? "I will increase my oral intake of fluids." "I will avoid the intake of thiazide diuretics." "I will avoid the intake of medications containing vitamin D." "I will increase my intake of antacids containing calcium."

"I will increase my intake of antacids containing calcium."

A nurse is teaching on the preoperative management of a patient with a pheochromocytoma. Which statement indicates the need for further teaching? Select all that apply. "I will put the patient on bedrest in the supine position." "I will place the patient on a cardiac monitor to assess for cardiac dysrhythmias." "I will administer a smooth muscle relaxant." "I will monitor the patient for hypotensive crisis." "I will monitor the patient for hemorrhage."

"I will put the patient on bedrest in the supine position." "I will monitor the patient for hypotensive crisis." "I will monitor the patient for hemorrhage."

A nurse is teaching on the preoperative management of a patient with a pheochromocytoma. Which statement indicates the need for further teaching? Select all that apply. "I will put the patient on bedrest in the supine position." "I will place the patient on a cardiac monitor to assess for cardiac dysrhythmias." "I will administer a smooth muscle relaxant." "I will monitor the patient for hypotensive crisis." "I will monitor the patient for hemorrhage."

"I will put the patient on bedrest in the supine position." "I will monitor the patient for hypotensive crisis." "I will monitor the patient for hemorrhage." (this would be post-op)

The nurse is teaching about care considerations for patients with the type of burn in this image. Which statement indicates a need for further teaching? "The burned area should be dressed properly." "Fragrance-free lotion should be applied twice a day." "Ice should be applied immediately after burns." "The patient should take plenty of fluids to rehydrate."

"Ice should be applied immediately after burns."

A patient is diagnosed with secondary adrenal insufficiencies and asks the nurse what that means. How should the nurse explain? "It occurs due to cancer." *It occurs due to traumatic processes". "It occurs due to autoimmune diseases." "It occurs due to disorders of the hypothalamus."

"It occurs due to disorders of the hypothalamus." (Rationale: Hypothalamus disorders are causes of secondary or tertiary adrenal insufficiency. - Primary Adrenal Insufficiency = Cancer, Autoimmine, Traumatic processes)

The nurse is teaching a community group about burn prevention strategies to be followed to prevent burns at home. Which statement made by someone in the group indicates a need for further teaching? "Smoke alarms should be checked every year." "The windows and the doorways should be kept free of clutter." "The water heater should not be set above 120° Fahrenheit." "Carbon monoxide detectors should be installed and maintained on each level of the home."

"Smoke alarms should be checked every year.

While assessing an injured patient's condition, the nurse suspects that the patient has an inhalational injury. Which clinical findings are likely responsible for the nurse's suspicion? Select all that apply. Facial burns Singed facial hair Sluggish blood flow Carbon in the sputum Decreased circulating blood volume

Facial burns Singed facial hair Carbon in the sputum

The nurse is teaching a patient about their upcoming water deprivation test. What should be included in the instructions? "You will drink a lot of water at the beginning of the test." "We will measure your body weight at the beginning and end of the test." "We will take a sample and assess your urine osmolality every 4 hours." "We will draw your blood hourly and compare serum osmolality with urine osmolality."

"We will draw your blood hourly and compare serum osmolality with urine osmolality."

A patient with a pituitary tumor undergoes a transsphenoidal hypophysectomy. What would be a priority postoperative action? Evaluate clear nasal drainage for glucose. Keep head of bed flat to prevent cerebrospinal fluid leak. Assist patient with oral care to keep the surgical area clean. Encourage coughing to prevent respiratory complications.

Evaluate clear nasal drainage for glucose.

DI - Urine Osmolality > 200 MILLIOSMOLE/KILOGRAM < 200 MILLIOSMOLE/KILOGRAM

< 200 MILLIOSMOLE/KILOGRAM (Decreased urine osmolality of less than 200 mOsm/kg is a key indicator of DI. This is a result of the water eliminated in the urine.)

Which diagnostic test is most appropriate to use in a patient with electrical burn injuries? Chest x-ray Creatine kinase-myocardial band (CK-MB) levels Altered blood gases Radiographic examination

Creatine kinase-myocardial band (CK-MB) levels

The nurse is assessing this patient with adrenal insufficiency. What is the reason for the skin pigmentation? Excess corticotropin releasing hormone (CRH) release Excess ACTH release Decreased cortisol release Decreased aldosterone release

Excess ACTH release

A patient presents with these laboratory values: Glucose: 159 mg/dL Sodium 150 mEq/L Potassium 2.6 mEq/L Order the hormonal *sequence* of events that would cause these serum levels. Anterior pituitary secretion of adrenocorticotropic hormone (ACTH) Adrenal secretion of corticosteroids and mineralocorticoids Hypothalamus secretion of corticotropin-releasing hormone (CRH) Abnormal serum levels

Abnormal serum levels Hypothalamus secretion of corticotropin-releasing hormone (CRH) Anterior pituitary secretion of adrenocorticotropic hormone (ACTH) Adrenal secretion of corticosteroids and mineralocorticoids Abnormal serum levels

Which action is most appropriate for the nurse to take when caring for a patient with hypofunction of the gonads? Administer prescribed vitamin D medication. Implement safety measures to reduce falls. Administer prescribed hormone replacement. Collaborate with physical therapy.

Administer prescribed hormone replacement.

A nurse is teaching a group of students about hormone secretion from the pituitary gland. Which hormones are secreted by the anterior lobe of the gland? Select all that apply. Adrenocorticotropic hormone (ACTH) Follicle-stimulating hormone (FSH) Growth hormone (GH) Thyroid-stimulating hormone (TSH) Antidiuretic hormone (ADH)

Adrenocorticotropic hormone (ACTH) Follicle-stimulating hormone (FSH) Growth hormone (GH) Thyroid-stimulating hormone (TSH)

Can you identify the symptoms associated with various thyroid and parathyroid disorders? Drag and drop the appropriate symptoms for each condition to the corresponding box. Post-op thyroidectomy complications Hypertension Airway occlusion Hemorrhage Constipation Hypocalcemia Laryngeal nerve damage Dysrhythmias Vomiting

Airway occlusion Hemorrhage Hypocalcemia Laryngeal nerve damage (Rationale: The post-operative client is at highest risk of airway occlusion, hemorrhage, hypocalcemia, and laryngeal nerve damage. Positioning should include semi-Fowler's to ease the work of breathing and decrease aspiration risks. A tracheostomy tray should be maintained at the bedside in case it is needed emergently. It is important to assess for tetany, which can cause laryngospasm that can block the airway. Bleeding is the highest risk in the first 24 hours. Laryngeal nerve damage will cause changes in the voice quality.)

The laboratory test results of a patient show a significant hyponatremia. What hormone imbalance should the nurse consider as the cause? Cortisol Aldosterone Growth hormone Follicle-stimulating hormone (FSH)

Aldosterone (Rationale: Hyponatremia is the condition in which there is a decrease in the level of sodium in the body. A decreased secretion in adrenocorticotropic hormone results in the decrease of the release of the mineralocorticoids (aldosterone) and glucocorticoids (cortisol) from the adrenal cortex. Aldosterone deficiency leads to hyponatremia.)

A client is experiencing sudden tachycardia, systolic hypertension, and a high fever after a thyroid assessment by the provider. What medication should be administered? Select all that apply. Antithyroid medications Thyroid supplements Vitamin D Iodine preparations Glucocorticoids

Antithyroid medications Iodine preparations Glucocorticoids (Rationale: Thyroid storm or thyrotoxicosis may develop with poorly managed hyperthyroidism. Clinical manifestations include tachycardia, fever, systolic hypertension, abdominal pain, tremors, and changes in level of consciousness. Airway management and fluid resuscitation are priorities. Antithyroid medications may be administered along with iodine preparations. For management of tachycardia, beta-adrenergic blockers may be administered. Glucocorticoids may also be administered because in high doses these medications decrease the conversion of T4 to the more active T3, as well as decreasing the release of TSH from the anterior pituitary gland.)

After serum testing, it is determined that a patient has a deficiency of adrenocorticotropic hormone (ACTH)? What concern should the nurse be aware of? Dwarfism Osteoporosis Circulatory collapse Ventricular tachyarrhythmias

Circulatory collapse (Rationale: The decreased secretion of ACTH would result in decreased glucocorticoids and mineralocorticoids. Therefore, the patient would be unable to maintain an adequate fluid volume status. Such a condition may result in circulatory collapse.)

The nurse caring for the client with burns knows which factors may impact the severity of the burn injury? Select all that apply. Client's age Client's gender Physical location of the burn Client's past medical history Involvement of an inhalation injury with the burn

Client's age Physical location of the burn Client's past medical history Involvement of an inhalation injury with the burn

Which interventions should the nurse implement when caring for the patient who has undergone a transsphenoidal hypophysectomy? Select all that apply. Conduct a neurological assessment. Maintain the head of the bed at a 30° angle. Provide frequent mouth care. Monitor the nasal drainage pad. Obtain urine-specific gravity every hour.

Conduct a neurological assessment. Provide frequent mouth care. (mouth dryness) Monitor the nasal drainage pad. (assess for CSF) Obtain urine-specific gravity every hour. (specimens collected every 6)

The nurse receives hand-off report for a patient with a history of hypothyroidism. Which symptoms should the nurse ask about to determine how well the patient is managing the illness? Insomnia Weight loss Constipation Tachycardia

Constipation

Prolonged use of which type of medication can lead to Cushing's syndrome? Angiotensin-converting enzyme inhibitor Nonsteroidal anti-inflammatory Anticoagulant Corticosteroid

Corticosteroid

The nurse recognizes that a patient needs glucocorticoid replacement for adrenal insufficiency. Which hormone replacement should the nurse request from the provider? Cortisol Adrenaline Aldosterone Norepinephrine

Cortisol

Which hormones are produced by the adrenal glands? Select all that apply. Insulin Cortisol Epinephrine Aldosterone Norepinephrine

Cortisol Epinephrine Aldosterone Norepinephrine

DI - Antidiuretic hormone (ADH) production INCREASED DECREASED

DECREASED (ADH secretion is decreased as a result of damage to the posterior pituitary gland. This decrease causes the body to excrete more water.)

A patient with hypocortisolism is hospitalized after experiencing a fall from orthostatic hypotension. Which additional symptom will be present? Decreased bone density Decreased blood pressure Decreased blood glucose level Decreased blood potassium level

Decreased blood glucose level (Rationale: Hypoglycemia is r/t decreased secretion of adrenocorticotropic hormone. This results in decreased release of cortisol.)

The nurse is caring for a patient with a history of poorly controlled hypothyroidism. What assessment indicates that medication adjustments are needed? Select all that apply. Hypertension Decreased body temperature Lower oxygen saturation Weight gain Oily skin

Decreased body temperature Lower oxygen saturation Weight gain

The nurse suspects hypoparathyroidism after reviewing the laboratory reports of a patient. Which findings support the nurse's suspicion? Select all that apply. Decreased calcium levels Increased vitamin D levels Increased magnesium levels Elevated phosphate levels Decreased parathyroid hormone

Decreased calcium levels Elevated phosphate levels Decreased parathyroid hormone

The patient newly diagnosed with acute adrenal insufficiency is prescribed hydrocortisone sodium succinate 100 mg IV for one dose. What action should the nurse take? Deliver the medication as written. Question the use of this medication. Question the dose being delivered. Request a mineralocorticoid along with this.

Deliver the medication as written. (50 to 100 mg hydrocortisone sodium succinate is an appropriate dose)

Review the events within the health record below. Select the priority request by the nurse when performing a Situation, Background, Assessment, Recommendation (SBAR) communication with the provider. *Health Hx & Symptoms*: Increasing HAs & visual disturbances over the last 2 months. CT scan confirms a benign pituitary tumor that was removed 12 hrs ago. *Lab Report*: Na+ 150, Serum Osmo 310, Urine SP 1.005 *Nursing Notes*: BP 98/54, HR 120, UO increased to 1200 mL/hr over the last hr. Call placed to provider IV D5 and 0.45% NaCl at 200 mL/hr Desmopressin 0.05 mg orally no Daily weight High sodium diet

Desmopressin 0.05 mg orally no

The nursing is caring for a patient with newly diagnosed idiopathic diabetes insipidus (DI). Which of the following should the nurse include in patient teaching? Pineal tumor is commonly the cause. Destruction of the cells of the hypothalamus lead to the condition. Traditional craniotomy is the reason for this. Head trauma often causes the condition.

Destruction of the cells of the hypothalamus lead to the condition.

The nurse is explaining to the nursing student that a client can have burns from events other than thermal injuries. What are types of burns that the nurse would include in the discussion with the student? Select all that apply. Electrical Chemical Radiation Biological Agricultural

Electrical Chemical Radiation

Can you identify the symptoms associated with various thyroid and parathyroid disorders? Drag and drop the appropriate symptoms for each condition to the corresponding box. Hyperparathyroidism Low magnesium levels Hypotension Elevated calcium levels Paresthesia of the hands and feet Decreased phosphorus levels Muscle weakness and atrophy Low back pain Tetany

Elevated calcium levels Decreased phosphorus levels Muscle weakness and atrophy Low back pain (Rationale: Hyperparathyroidism is characterized by symptoms of hypercalcemia, hypophosphatemia, muscle weakness and atrophy, low back pain, increased incidence of pathological fractures, ventricular dysrhythmias, constipation, anorexia, nausea and vomiting, and renal stones.)

A patient with an endocrine disorder is prescribed propylthiouracil (PTU) and lithium carbonate. Which laboratory finding supports the prescription? Decreased serum thyroxine (T4) Elevated serum triiodothyronine (T3) Low plasma parathyroid hormone (PTH) levels Elevated plasma PTH levels

Elevated serum triiodothyronine (T3)

The nurse is caring for a patient with adrenal hypersecretion. What action is appropriate? Increase protein in the diet. Avoid using tape on the skin. Limit fiber intake. Encourage fluid intake.

Encourage fluid intake. (Skin is thin & friable. No fluid bc fluid retention occurs in adrenal hypersecretion -> sodium & water reabsorption -> Hyponatremia)

The healthcare team is caring for a patient with the burn injuries in the image. Which medication is the primary healthcare provider most likely to prescribe to promote venous return and to prevent thromboembolism? Enoxaparin Zolpidem Propofol Lorazepam

Enoxaparin

Which hormones should the nurse anticipate being affected for a client who is diagnosed with an adrenal medulla tumor? Select all that apply. Insulin Cortisol Epinephrine Aldosterone Norepinephrine

Epinephrine Norepinephrine

A nurse is working with unlicensed assistive personnel (UAP) in caring for a group of patients. Which action should the nurse delegate to the UAP first? Measure the urine output in the catheter of a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Record the breakfast fluid intake for a patient with SIADH. Fill the water pitcher of a patient with diabetes insipidus (DI). Take the vital signs on all the patients.

Fill the water pitcher of a patient with diabetes insipidus (DI).

A nursing is talking with a neighbor experiencing infertility and a low sperm count from a hormone imbalance. Which hormone affects spermatogenesis? Growth-stimulating hormone (GSH) Follicle-stimulating hormone (FSH) Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH)

Follicle-stimulating hormone (FSH)

Identify the hormones secreted from the adrenal cortex. Select all that apply. Glucocorticoids Adrenocorticotropic hormone Catecholamines Mineralocorticoids Corticotropin-releasing hormone

Glucocorticoids (cortisol) Mineralocorticoids (aldosterone)

DI - Hematocrit HEMODILUTION HEMOCONCENTRATION

HEMOCONCENTRATION (DI causes a rise in hematocrit levels resulting in hemoconcentration of the blood due to fluid loss.)

Serum sodium HYPERNATREMIA HYPONATREMIA

HYPERNATREMIA (Rationale: As the blood loses water, it becomes more concentrated and the serum sodium level rises.)

Releasing gland of corticotropin-releasing hormone (CRH) ANTERIOR PITUITARY HYPOTHALAMUS POSTERIOR PITUITARY

HYPOTHALAMUS (CRH is released from the hypothalamus, targeting the anterior pituitary gland to release ACTH.)

The nurse is caring for a client who states: "I'm cold all of the time and I've gained about 10 pounds in the last month. I sleep a lot, I'm not sure what is wrong with me." What additional assessment should the nurse perform? Select all that apply. Heart rate and blood pressure Temperature Chvostek sign Bowel habits 24-hour diet recall

Heart rate and blood pressure Temperature Bowel habits 24-hour diet recall

Can you identify the symptoms associated with various thyroid and parathyroid disorders? Drag and drop the appropriate symptoms for each condition to the corresponding box Hyperthyroidism Heat intolerance Insomniac Nervousness Chvostek Sign Hypercalcemia Weight gain Decreased T3 and T4 levels Decreased TSH

Heat intolerance Insomnia Nervousness (Hyperthyroidism is a result of increased TSH and thyroid hormone levels in the blood. Symptoms include tachycardia, dysrhythmias, increased heart sounds, thyroid bruit, heat intolerance, increased bowel movement, increased appetite, weight loss, fatigue, nervousness, insomnia, light to absent menses, and hair loss.)

Rosie has experienced a significant burn from a house fire. She is in the intensive care unit on a ventilator.Drag and drop the lab that is elevated from her dehydration. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

Hematocrit (Plasma is lost to extravascular spaces, leaving the remaining blood very viscous that causes the hematocrit to increase.)

The nurse suspects laryngeal nerve damage in a patient who has undergone a thyroidectomy. Which symptom supports the nurse's suspicion? Hoarseness of the voice Bleeding around the dressing Difficulty in breathing Increased viscosity in nasal secretions

Hoarseness of the voice

Which medications are used for pain management in patients with burns? Select all that apply. Zolpidem Hydromorphone Lorazepam Fentanyl Morphine sulfate

Hydromorphone Fentanyl Morphine sulfate

Identify the lab abnormalities found with hypercortisolism. Select all that apply. Hypercalcemia Hyperglycemia Elevated sodium level Hyperkalemia Hypermagnesemia

Hyperglycemia Elevated sodium level

Which adverse reactions to the prescribed exogenous corticosteroid medication should the nurse monitor for? Select all that apply. Hyperglycemia Fluid retention Increased muscle mass Abnormal fat distribution Decreased serum potassium

Hyperglycemia Fluid retention Abnormal fat distribution Decreased serum potassium (An adverse reaction to prescribed exogenous corticosteroid medication is Cushing's syndrome. Cushing's syndrome manifests with hyperglycemia, fluid retention, hypokalemia, and abnormal fat distribution. This syndrome also manifests with decreased, not increased, muscle mass. Other clinical manifestations of Cushing's syndrome for Mrs. DeToro may include virilization (male sexual characteristics developing in females), breast atrophy, vocal changes (deepening), and amenorrhea.)

Which clinical manifestation is the nurse most likely to see in a patient with a pheochromocytoma? Select all that apply. Bradycardia Hypotension Hypoglycemia Hyperhidrosis Hypermetabolism

Hyperhidrosis Hypermetabolism

hich clinical manifestation would indicate to the nurse that the client may have pheochromocytoma? Hypertension Hypoglycemia Hyponatremia Hyperpigmentation

Hypertension

Mrs. DeToro is at risk for pheochromocytoma as a result of the current diagnosis. Which assessment is the priority to monitor for while providing care? Eupnea Bradycardia Hypertension Hypoglycemia

Hypertension (Pheochromocytomas are rare catecholamine-secreting tumors of the adrenal medulla and, in 50% of cases, are diagnosed only upon autopsy. Clinical manifestations of this disorder are related to the systematic actions of epinephrine and norepinephrine and include tachycardia (not bradycardia), hypertension, headaches, palpitations, hyperhydrosis, hypermetabolism, and hyperglycemia (not hypoglycemia). Eupnea, the term for normal respirations, would not be assessed for as a result of this complication. The severity of attacks correlates to the amount of catecholamine release. Paroxysmal (sudden-onset) hypertension is seen in some patients, with blood pressure elevations in excess of 250/140 mm Hg, posing a life-threatening emergency.)

The nurse is caring for a client with exophthalmos. What is the anticipated cause? Hypothyroidism Hyperthyroidism Thyrotoxicosis Hypoparathyroidism

Hyperthyroidism

The nurse is caring for a client with excess catecholamine. What assessment changes should be anticipated? Select all that apply. Bradycardia Hypoactive bowel sounds Diaphoresis Pupil constriction Hypertension

Hypoactive bowel sounds Diaphoresis Hypertension (Affects of norepinephrine & epinephrine release)

The nurse is providing care for a 35-year-old female client, Mrs. DeToro, who was admitted to the hospital with weakness, fatigue, nausea, and abdominal pain. When conducting the health history, Mrs. DeToro tells the nurse that she was diagnosed with Addison's disease a year ago and is concerned that her current symptoms might be related to her diagnosis. Which assessment findings support the nurse's suspicion that Mrs. DeToro is experiencing an adrenal crisis? Select all that apply. Hypoglycemia Hyperkalemia Hypernatremia Severe hypotension Severe hypovolemia

Hypoglycemia Hyperkalemia Severe hypotension Severe hypovolemia (Adrenal crisis is a life-threatening emergency that leads to severe hypovolemia and hypotension. The client is also at risk for hyperkalemia and hypoglycemia related to lack of mineralocorticoids and glucocorticoids. Risk factors for adrenal crisis include stressful events such as trauma, surgery, and infections.)

It is determined that a patient has decreased mineralocorticoids due to hypopituitarism. Which laboratory abnormality is most important for the nurse to monitor? Hypoglycemia Hyponatremia Decreased cortisol levels Decreased catecholamine levels

Hyponatremia

Which clinical manifestations should the nurse anticipate when providing care to a client experiencing Addison's disease? Select all that apply. Hyperglycemia Hyponatremia Hyperkalemia Hypertension Hypocalcemia

Hyponatremia Hyperkalemia

A patient with a pheochromocytoma has undergone unilateral adrenalectomy. What is the priority in the postoperative patient? Excessive sweating Weight loss Hypotension Premature ventricular contractions

Hypotension (Hemorrhage & hypovolemic shock)

To resolve fluid volume deficits and correct plasma osmolality, what type of fluid would be used in the treatment of diabetes insipidus? Hypotonic fluid such as 5% dextrose in water Isotonic fluid such as Ringer's lactate Colloid fluid such as albumin Isotonic fluid such as 5% dextrose in water

Hypotonic fluid such as 5% dextrose in water (Rationale: Water losses are replaced with a hypotonic fluid (in relation to the patient's serum osmolality) such as dextrose in water. During IV administration, the patient is monitored for hyperglycemia, volume overload, and correction of hypernatremia. Decreasing the serum sodium by 0.5 mmol/L every hour minimizes the chances of overly rapid correction of hypernatremia.)

A patient is admitted with complications from poorly maintained hypothyroidism. What symptoms should the nurse anticipate? Tetany Hypoventilation Renal stones Graves' disease

Hypoventilation

DI - Serum Osmolality INCREASED DECREASED

INCREASED (In DI, one would expect to see an increase in serum osmolality from the loss of water in the urine.)

Mrs. DeToro's laboratory values indicate she is experiencing an adrenal crisis. Which treatment should the nurse anticipate? Select all that apply. Digoxin Furosemide Sliding scale insulin IV fluid with glucose IV glucocorticoids

IV fluid with glucose IV glucocorticoids (Cortisol replacement is the definitive treatment for adrenal insufficiency. Patients presenting with acute adrenal insufficiency require emergency stabilization with IV fluids and glucose, along with IV administration of glucocorticoids (cortisol), such as 50 to 100 mg of hydrocortisone sodium succinate (Solu-Cortef) or 4 to 12 mg of dexamethasone (Decadron))

The nurse receives several prescriptions for Mrs. DeToro. Which is the priority to administer? IV furosemide (Lasix) IV glucocorticoid (Cortisol) PO sodium polystyrene sulfonate (Kayexalate) PO hydrocortisone sodium succinate (Solu-Cortef) Check Answer

IV glucocorticoid (Cortisol) (The priority medication for this client is an IV glucocorticoid such as Cortisol. IV furosemide (Lasix) is not appropriate for this patient as a hallmark finding for adrenal crisis is fluid volume deficit, not fluid volume excess. Kayexalate is only administered if the client is experiencing hyperkalemia. While PO Solu-Cortef may be appropriate for Mrs. DeToro, the definitive treatment is IV cortisol.)

What is the cause of about a third of clinical cases of diabetes insipidus? Brain tumors Head trauma Intracranial surgery Idiopathic

Idiopathic (Rationale: Approximately 30% of cases of DI are idiopathic, whereas 25% are secondary to brain tumors, 20% develop after intracranial surgery, and 16% occur after head trauma. Idiopathic DI develops secondary to destruction of the cells of the hypothalamus that produce ADH and is often an autoimmune process.)

The patient presents with a decreased serum osmolality and sodium level along with hypertension, tachycardia, and concentrated urine. What action by the nurse is a priority? Encourage the patient to take fluids. Administer desmopressin as prescribed. Administer humidified oxygen as ordered. Implement seizure precautions.

Implement seizure precautions.

The nurse is performing discharge instructions with a client newly diagnosed with hyperparathyroidism. What should be included? Select all that apply. Increase food with fiber Signs of high and low calcium levels Limit oral fluids Strain urine for stones Take a daily laxative

Increase food with fiber Signs of high and low calcium levels Strain urine for stones (Rationale: • Signs of hypocalcemia and hypercalcemia: This information is needed to prevent complications associated with the extremes of either calcium abnormality. • Low-calcium diet: Decreased consumption of calcium may lead to lower serum calcium levels .• Increase fluids and fiber to decrease complications of constipation: Delayed gastric motility secondary to effects of calcium on smooth muscle leads to constipation.)

Can you identify the symptoms associated with various thyroid and parathyroid disorders? Drag and drop the appropriate symptoms for each condition to the corresponding box. Hypothyroidism Increased TSH secretion Decreased T3 and T4 levels Hair loss Hypothermia Thyroid bruit Diarrhea Cold intolerance Cardiac dysrhythmias

Increased TSH secretion Decreased T3 and T4 levels Hypothermia Cold intoleranced (Rationale: Hypothyroidism is caused from a decreased level of thyroid hormones from the thyroid gland. The TSH is elevated as the pituitary gland senses the low blood levels. Symptoms include bradycardia, bradypnea, hypothermia, weight gain, elevated cholesterols, increased sleep, weakness, muscle aches, anorexia, constipation, cold intolerance, and decreased libido.)

The nurse is assessing a patient with elevated T3 and T4 levels. Which assessments correlate with this finding? Select all that apply. Increased appetite Increased weight gain Increased sleep Increased heart sounds Increased number of bowel movements

Increased appetite Increased heart sounds Increased number of bowel movements

A client experiencing thyroid storm is severely tachycardic and hypertensive. Which medications should the nurse prepare to deliver? Select all that apply. Synthroid Iodine preparations Beta-adrenergic blockers Glucocorticoids Antithyroid medications

Iodine preparations Beta-adrenergic blockers Glucocorticoids Antithyroid medications

The physician may order a replacement antidiuretic hormone such as desmopressin. How can this be administered? Select all that apply. It can be administered via intranasal route. It can be given orally. It can be given in an IV. It can be given subcutaneously. It can be given transdermally.

It can be administered via intranasal route. It can be given orally. It can be given subcutaneously.

Which is true regarding a pheochromocytoma? It is the increased secretion of aldosterone. It is the excessive secretion of glucocorticoids. It is the excessive secretion of catecholamines by adrenal medulla. It is the decreased secretion of adrenocorticotropic hormone from the anterior pituitary gland.

It is the excessive secretion of catecholamines by adrenal medulla.

The nurse is caring for a patient with a deep partial thickness burn. Which statement is correct? It affects the epidermal layer of the skin. It gets resolved in 24 to 72 hours. It may cause pain in various areas with decreased sensation. It is often referred to as eschar.

It may cause pain in various areas with decreased sensation.

Which is true regarding the Lund and Browder method to determine the percentage of total body surface area burned? It is used in prehospital settings. It is used for superficial, partial, and full thickness burns. It takes into consideration the patient's hand as well as the fingers. It requires thorough burn wound debridement.

It requires thorough burn wound debridement.

The nurse is caring for the patient in the image (hypothyroid). What medications should the nurse anticipate will be delivered? Levothyroxine Propylthiouracil (PTU) Lithium carbonate Iodine

Levothyroxine

The nurse is preparing to admit a patient from the emergency department who is experiencing thyrotoxicosis. What should the nurse include in the plan? Select all that apply. Provide warming blankets. Maintain patent airway. Limit fluid intake. Take seizure precautions. Monitor for cardiac dysrhythmias.

Maintain patent airway. Take seizure precautions. Monitor for cardiac dysrhythmias.

The nurse is caring for a patient with adrenocorticotropic hormone (ACTH) deficiency. What should be included in the plan of care? Preventing the risk for injury Providing a diet rich in calcium Increasing the intake of vitamin D Maintaining adequate volume of fluid intake

Maintaining adequate volume of fluid intake (Rationale: Fluid volume deficiency is related to decreased glucocorticoid and mineralocorticoid levels, which is related to ACTH deficiency. Maintaining adequate fluid levels in a patient with ACTH deficiency is an important intervention.)

A patient reports insomnia, weight loss, and increased appetite. The laboratory reports of the patient indicate elevated serum triiodothyronine (T3) and thyroxine (T4). Which action is the priority? Administer sedatives. Manage cardiac function. Ensure adequate fluid intake. Provide a stress-free environment.

Manage cardiac function.

The nurse is caring for a client who is returning from surgery after a thyroidectomy. What is the priority of care? Weight loss over time Management of the airway Minimizing use of vocal cords Monitoring for hypercalcemia

Management of the airway (Rationale: Postoperative priorities after thyroidectomy include monitoring for airway compromise, hemorrhage, hypocalcemia secondary to removal of all parathyroid gland tissue, and damage to the laryngeal nerve.)

Which is the most likely cause for the development of hyperkalemia in the emergent phase of a burn injury? Massive cellular trauma Plasma leakage through damaged capillaries Loss of bicarbonate ions Decreased renal blood flow

Massive cellular trauma

A client with a major burn injury is at great risk of burn shock. What factor causes this type of shock? Infection Massive fluid shift Loss of blood Organ dysfunction

Massive fluid shift

A patient was admitted to the hospital with superficial burns. Which clinical manifestations are likely to be observed in the patient? Select all that apply. Mild erythema Hypersensitivity Waxy appearance Wet blisters Leathery skin

Mild erythema Hypersensitivity

Which is a priority when caring for a patient with a pheochromocytoma? Monitoring for hypoglycemia Monitor for orthostatic hypotension Monitor for bradycardia Monitor for neurological changes

Monitor for neurological changes (Pheochromocytoma = excessive adrenal medulla fx -> increased epi & norepinephrine -> tachycardia, HTN, hyperglycemia)

Mrs. DeToro is admitted to the medical-surgical unit for further monitoring. Which actions are appropriate? Select all that apply. Monitor intake and output Assess for hypertension Monitor blood glucose Administer IV cortisone Place the bed in the lowest position

Monitor intake and output Monitor blood glucose Administer IV cortisone Place the bed in the lowest position (The nursing assessment for a patient who is experiencing an adrenal crisis should include monitoring intake and output as well as blood glucose. Fluid loss occurs secondary to lack of mineralocorticoid and glucocorticoid, leading to loss of sodium followed by loss of water through the kidneys. Hypoglycemia occurs due to decreased cortisol. You would monitor for hypotension, not hypertension. IV cortisone is a priority for the treatment of the adrenal crisis and placing the bed in the lowest position is for safety)

Can you identify the symptoms associated with various thyroid and parathyroid disorders? Drag and drop the appropriate symptoms for each condition to the corresponding box. Hypoparathyroidism Negative Trousseau sign Numbness and tingling around the mouth, hands and feet Severe muscle cramps Decreased phosphorus levels Increased incidence of pathological fractures Positive Chvostek's sign Decreased calcium levels Constipation

Numbness and tingling around the mouth, hands and feet Severe muscle cramps Positive Chvostek's sign Decreased calcium levels (Rationale: Hypoparathyroidism results in low calcium levels, tingling and spasms of the muscles, a positive Chvostek and Trousseau sign, tetany, seizures, prolonged QT interval, digitalis resistance, hypotension, and bone pain.)

Which nursing interventions should the nurse provide when caring for a patient who has undergone a thyroidectomy? Select all that apply. Observe for postoperative bleeding. Use sand bags to keep the head in position. Position the patient flat on the back. Administer humidified air. Maintain the tracheostomy tray at the patient's bedside for 24 hours after surgery.

Observe for postoperative bleeding. Use sand bags to keep the head in position. Administer humidified air. (Trach Tray & oral suctioning for first 48 hrs)

The patient with adrenal hypersecretion is concerned about long-term health concerns. What should the nurse educate the patient about? Osteoporosis Diabetes mellitus Gastrointestinal bleeding Liver failure Pancreatitis

Osteoporosis Diabetes mellitus Gastrointestinal bleeding Liver failure Pancreatitis

Which patient is most likely to have Addison's disease? Patient A - Cortisol (morning): 2 mcg/dL - Glucose: 68 mg/dL Patient B - Cortisol (morning): 24 mcg/dL - Glucose: 118 mg/dL Patient C - Cortisol (morning): 19 mcg/dL - Glucose: 82 mg/dL Patient D - Cortisol (morning): 26 mcg/dL - Glucose: 130 mg/dL

Patient A

The nurse is receiving hand-off reports for four patients. Which patient presents with a serum sodium level consistent with diabetes insipidus (DI)? Patient A: 148 mg/dL Patient B: 140 mg/dL Patient C: 136 mg/dL Patient D: 128 mg/dL

Patient A: 148 mg/dL

The nurse receives hand-off report on 4 patients. In evaluating the laboratory report, which patient is at the greatest risk of experiencing syndrome of inappropriate antidiuretic hormone (SIADH)? *Patient A* - USG: 1.010 - Serum Osmol: 310 - Sodium: 149 *Patient B* - USG: 1.002 - Serum Osmol: 295 - Sodium: 133 *Patient C* - USG: 1.028 - Serum Osmol: 300 - Sodium: 145 *Patient D* - USG: 1.034 - Serum Osmol: 274 - Sodium: 130

Patient D

Which patient is most likely to have Conn's syndrome? Patient A: Serum Na+ 142 mg/dL Patient B: Serum K+ 5.8 mmol/L Patient C: BP 86/58 mm Hg Patient D: BP 167/100 mm Hg

Patient D

Which patient is most likely to have Cushing's disease? Patient A: - Cortisol (morning): 8 mcg/dL - Glucose: 80 mg/dL Patient B: - Cortisol (morning): 13 mcg/dL - Glucose: 90 mg/dL Patient C - Cortisol (morning): 15 mcg/dL - Glucose: 98 mg/dL Patient D - Cortisol (morning): 19 mcg/dL - Glucose: 110 mg/dL

Patient D

The nurse receives hand-off on these patients. Which should the nurse assess first? Patient being treated for syndrome of inappropriate antidiuretic hormone (SIADH). HR 116 bpm, BP 167/99 (122) mm Hg, RR 24, Sats 93% on room air. Patient being treated for diabetes insipidus. HR 99 bpm, BP 88/50 mm Hg when ambulating, Sats 95% on room air Patient being treated for SIADH with a serum sodium of 120 mEq/L. Patient being treated for diabetes insipidus with a urine output of 100 mL/hour.

Patient being treated for SIADH with a serum sodium of 120 mEq/L. (Sodium is at a critical level - risk for seizure)

The nurse is caring for a client at risk for developing diabetes insipidus. What is the initial assessment change the nurse should anticipate? Polyuria Hypotension Polydipsia Polyphagia

Polyuria

The nursing is admitting a patient from home. Which presenting symptom causes the nurse to be concerned that the patient has developed diabetes insipidus (DI)? Hypertension Bradycardia Polyuria Decreased serum sodium

Polyuria

The nurse is concerned about high sodium levels in her patient experiencing diabetes insipidus. Which is the priority nursing action? Supplement the reciprocal hypokalemia. Complete hourly neurological assessments. Provide safety precautions for seizures. Monitor hourly urine output.

Provide safety precautions for seizures.

A transsphenoidal approach is used to treat pathological etiologies of diabetes insipidus. Which nursing actions would be included in the post-operative plan of care for clients who undergo this procedure? Select all that apply. Insertion of nasogastric tube to allow for enteral feedings Providing oxygen therapy as needed Providing client with cooling blanket to prevent hyperthermia Providing oral fluids if client is alert and awake Maintaining head of bed between 45 and 60 degrees

Providing oxygen therapy as needed Providing oral fluids if client is alert and awake Maintaining head of bed between 45 and 60 degrees

A client is suspected of having diabetes insipidus and is admitted to the medical-surgical nursing unit. Which diagnostic tests does the nurse anticipate the physician will order? Select all that apply. Serum and urine electrolytes CT scan Osmolality Urine-specific gravity Lumbar puncture

Serum and urine electrolytes Osmolality Urine-specific gravity

Which diagnostic tests should the nurse anticipate will be ordered for Mrs. DeToro by the healthcare provider to evaluate her adrenal gland? Select all that apply. Serum potassium Serum magnesium Serum sodium Computed tomography (CT) Abdominal x-ray

Serum potassium Serum sodium Computed tomography (CT) (Appropriate diagnostic tests include serum potassium (to monitor for hypokalemia), serum sodium (to monitor for hyponatremia), and a CT scan (to assess for changes in the size and morphology of the adrenal gland). You would not anticipate a serum magnesium level nor an abdominal x-ray for this patient.)

Which clinical manifestation is most likely observed in a patient with 11% to 12% carbon monoxide poisoning? Tachypnea and tachycardia Disorientation and nausea Mild headache and confusion Severe headache and vision changes

Severe headache and vision changes

What is the basis of fluid therapy replacement for the treatment of diabetes insipidus? Serum osmolality is decreased as fluids are replaced rapidly. A fluid challenge is used to restore fluid volume. Additional fluids are needed in the intravascular space to maintain adequate fluid volume. Slowly decreasing the serum sodium decreases rapid correction of hypernatremia.

Slowly decreasing the serum sodium decreases rapid correction of hypernatremia.

The nurse is caring for a patient with a blood pressure of 250/140 mm Hg from an adrenal tumor. What medication should the nurse request when contacting the provider? Sodium nitroprusside (Nipride) Polystyrene sulfonate (Kayexalate) Pasireotide Dexamethasone

Sodium nitroprusside

Which medication is most likely to be administered to a patient with a pheochromocytoma who develops an intraoperative hypertensive episode? Sodium nitroprusside (Nipride) Polystyrene sulfonate (Kayexalate) Pasireotide Dexamethasone

Sodium nitroprusside (Nipride)

The client experiencing increased aldosteronism will experience which electrolyte abnormality? Sodium reabsorption Potassium reabsorption Glucose loss Magnesium loss

Sodium reabsorption

The patient with hyperaldosteronism is being treated for hypertension. What medication should the nurse anticipate? Metoprolol Lisinopril Spironolactone Furosemide

Sprionolactone (potassium-sparing diuretic)

The nurse is learning about burns. Which statement is true regarding radiation burns? These are the most common type of burn injury. Localized radiation injuries are similar in nature to electrical burns. Partial exposure to ionizing radiation causes nausea and vomiting. Sunburn is the most common type of radiation burn observed in healthcare settings.

Sunburn is the most common type of radiation burn observed in healthcare settings.

Jane has a burn that is affecting the epidermal layer of the skin. She does not require medical intervention.Drag and drop how this burn should be classified.

Superficial (A superficial burn only affects the epidermal (top) layer of skin and does not typically require medical intervention to heal.)

The nurse is caring for a client with decreased secretion of the anterior pituitary gland. What abnormalities should the nurse expect to find? Select all that apply. Symptoms of Addison's disease Symptoms of Cushing's disease Symptoms of hypothyroidism Symptoms of SIADH Symptoms of diabetes insipidus

Symptoms of Addison's disease Symptoms of hypothyroidism

Which hormones of the body function to maintain the metabolism of the body? Select all that apply. T3 PTH T4 FSH CRH

T3 T4

Heart rate TACHYCARDIA BRADYCARDIA

TACHYCARDIA (Dehydration will cause the heart rate to increase.)

Releasing gland of triiodothyronine (T3) and thyroxine (T4) POSTERIOR PITUITARY ANTERIOR PITUITARY THYROID

THYROID (T3 and T4 are released from the thyroid gland to the cells of the body to increase metabolic rate and response of catecholamines.)

The nurse is providing discharge instructions for a patient newly diagnosed with adrenal insufficiency. What is important to include? Select all that apply. Take oral hormone replacement weekly Wear a medic alert bracelet at all times Signs of adrenal crisis Rise from a sitting position slowly. Signs of corticosteroid excess

Take oral hormone replacement weekly Wear a medic alert bracelet at all times Signs of adrenal crisis Rise from a sitting position slowly. Signs of corticosteroid excess

Which instructions should the nurse provide for the patient prescribed levothyroxine for hypothyroidism? Select all that apply. The medication may be stopped once the symptoms disappear. Take the medication before bedtime. Take the medication at the same time every day. The dosage may be increased as needed. Inform health-care providers about the history of hypothyroidism.

Take the medication at the same time every day. The dosage may be increased as needed. Inform health-care providers about the history of hypothyroidism.

After several days in the hospital, Mrs. DeToro's condition has stabilized and she is approaching discharge. Which topics should the nurse include in the discharge teaching plan? Select all that apply. Taking oral hormone replacement daily Wearing a medical-alert bracelet when traveling Monitoring for symptoms of corticosteroid excess Using prescribed sedatives for sleep Monitoring for anticipated weight loss

Taking oral hormone replacement daily Monitoring for symptoms of corticosteroid excess (Topics that you should include in Mrs. DeToro's discharge teaching include the importance of taking oral hormone replacement daily and monitoring for symptoms of corticosteroid excess. A medical-alert bracelet should be worn at all times, not just when traveling. The client should be warned against the use of prescribed sedatives for sleep, as Mrs. DeToro's diagnosis contradicts this classification of medication. The client should be taught to monitor for weight gain, not weight loss, due to the prescribed glucocorticoids necessary for treatment.)

The nurse is aware the client with a burn has a deep partial thickness burn when making which assessment observation? The burn affects only the epidermal layer of the skin. The burn affects the epidermis through to the superficial layers of the dermis. The burn affects the epidermis through to the lower layers of the dermis. The burn affects the epidermis, dermis, and portions of the subcutaneous tissue.

The burn affects the epidermis through to the lower layers of the dermis.

The primary healthcare provider ordered fluid resuscitation for a patient with an electrical injury. Which findings observed by the primary healthcare provider determines that fluid resuscitation is adequate? Select all that apply. Urine output: 1 mL/kg/hr Systolic blood pressure: 110 mm Hg Heart rate: 100 beats per minute Central venous pressure: 15 mm Hg Bladder pressure: 10 mm Hg

Urine output: 1 mL/kg/hr Systolic blood pressure: 110 mm Hg Heart rate: 100 beats per minute

Tori has burns to the tissues of the neck after receiving treatment for thyroid cancer. The skin is red and excoriated.Drag and drop the cause of this type of burn. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

radiation (Radiation injuries are often associated with the industrial use of ionizing radiation, nuclear accidents, and therapeutic radiation treatment, such as radiation therapy used for cancer. Sunburn is also considered a radiation burn because it is caused by ultraviolet radiation and is the most common type of radiation burn seen in healthcare settings.)

The nurse is caring for a patient with a scant amount of concentrated urine. Which finding would suggest syndrome of inappropriate antidiuretic hormone (SIADH) is the cause? The patient appears dehydrated. The serum sodium level is increased. The serum osmolality is decreased. The specific gravity of the urine is increased.

The serum osmolality is decreased. (SIADH -> decreased serum sodium & serum osmolality. Specific gravity is increased)

The nurse is caring for a client who has a large full-thickness burn and is going to the operating room to have a burn excision. The nurse notes on the surgical consent that an allograft is planned. The tissue for an allograft is from which source? The client's own skin The skin from a pig The skin from a cadaver The skin grown in the lab from a biopsy of the client's own skin

The skin from a cadaver

The nurse is caring for a patient presenting with decreased levels of thyroid-stimulating hormone (TSH). What assessment finding should the nurse anticipate? Weight loss Thinning of hair Amenorrhea Hyperkalemia

Thinning of hair (Hypothyroidism -> decreased TSH? and decreased T3 & T4)

A patient with hypothyroidism is on thyroid replacement therapy. The primary health-care provider instructs the patient to take the medication in the morning at the same time every day. Which is the rationale for this instruction? To mimic the normal circadian rhythm To prevent an increase in cholesterol levels To prevent vasodilation and hypotension To avoid accelerated cardiovascular function

To mimic the normal circadian rhythm

The nurse is caring for a patient who began showing signs of diabetes insipidus (DI) 4 hours ago, and was treated with IV fluids and one dose of nasal desmopressin. How will the nurse know the treatment is effective? Select all that apply. Urine output will decrease. Urine specific gravity of 1.029. Blood pressure will lower. Glucose level will normalize. Sodium level change from 128 mEq/L to 134 mEq/L.

Urine output will decrease. Urine specific gravity of 1.029.

A patient is admitted with severe dehydration and hypotension. Which hormone, when delivered, increases water reabsorption? Oxytocin Vasopressin Luteinizing hormone Adrenocorticotropic hormone

Vasopressin (Rationale: Vasopressin increases water reabsorption.)

The laboratory reports of a patient with endocrine disorder indicate decreased thyroxine (T4) levels. Which clinical manifestation is likely to be present? Tetany Diarrhea Weight gain Tachycardia

Weight gain

The patient asks the nurse about the temporary graft they are receiving for their burn injury. Which type of graft is used as a temporary covering once eschar is removed to help close and protect the wound? Integra Autograft Xenograft Cultured epithelial autograft

Xenograft

Which zone of burn injury has the most contact with the heat source and is the location of the most severe damage? Zone of stasis Zone of hyperemia Zone of conversion Zone of coagulation

Zone of coagulation

The client presents with these labs. Which are consistent with the clinical diagnosis of diabetes insipidus? Select all that apply. BUN: 5 Sodium: 152 Hematocrit: 56 Urin Specific Gravity: 1.001 Serum Osmolality: 301 a. Decreased blood urea nitrogen b. Increased serum sodium c. Increased hematocrit d. Decreased urine specific gravity e. Increased serum osmolality

b. Increased serum sodium c. Increased hematocrit d. Decreased urine specific gravity e. Increased serum osmolality (Rationale: Urine-specific gravity of less than 1.005 and urine osmolality less than 200 mOsm/kg are key indicators of DI. While the patient loses free water, increases in serum sodium, serum osmolality, and hematocrit develop secondary to hemoconcentration)

Sarah works with caustic substances. She accidently spills an acidic agent on her arms and is taken to the burn unit for treatment.Drag and drop the cause of this type of burn. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

chemical (The three subclasses of chemical burns include acids, alkaline, and organic compounds. Some examples of chemical burns include those caused by cement, gasoline, lime, hydrofluoric acid, and bleach. Other types of burns include thermal, radiation, and electrical.)

The nurse is caring for Will, who has a deep partial thickness burn to the left lower extremity. What would be the priority nursing action related to the location of the burn?Drag and drop the priority nursing action for Will. superficial sodium level full thickness immediate respiratory assessment superficial partial-thickness monitor pedal pulses deep partial-thickness hematocrit radiation chemical

monitor pedal pulses (The nurse should closely monitor pedal pulses for the first 48 hours to assess for the potential development of compartment syndrome, a painful and serious condition in which pressure within the muscle builds to dangerous levels. The other nursing actions could be appropriate, but are not related specifically to the location of the burn.)