Endocrine

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first? 1. Administer as-needed dose of hydrocortisone intravenous (IV) push 2. Complete a head-to-toe assessment to identify any sources of infection 3. Document the findings in the client's electronic medical record 4. Take blood pressure sitting and standing to assess for orthostatic hypotension

1

The nurse is caring for a client with suspected Graves disease. Which assessment finding requires priority intervention? 1. Agitation and confusion 2. Heat intolerance 3. Pulse of 110/min, irregular rhythm 4. Red and bulging eyes

1

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply. 1. Decreased serum osmolality 2. High serum osmolality 3. High urine specific gravity 4. Increased urine output 5. Low serum sodium

1,3,5

The nurse teaches disease management to a group of clients with type I diabetes mellitus. Which of the following should the nurse teach as signs or symptoms associated with hypoglycemia? Select all that apply. 1. Diaphoresis 2. Flushing 3. Pallor 4. Polyuria 5. Trembling

1,3,5

A nurse is teaching a nutrition class for clients with newly diagnosed type 2 diabetes. Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning? 1. Baked tilapia with tomato salsa, Spanish-style rice 2. Black bean chili with brown rice, mixed green salad 3. Grilled chicken breast with baked French fries 4. Hamburger on a whole wheat bun with lettuce and tomato

2

The client's diabetes is controlled with 2 injections a day, each consisting of isophane (NPH) insulin and regular insulin. One injection is given before breakfast and the other is administered before dinner. The client lost 20 lb (9.1 kg) through dieting and exercise but has started having daily episodes of hypoglycemia with diaphoresis at about 4 PM. What change would be best for the nurse to discuss with the primary health care provider? 1. Decrease the morning NPH insulin dose 2. Decrease the morning regular insulin dose 3. Delay the evening insulin administration 4. Schedule an afternoon snack for the client

1

A grade-school client has type 1 diabetes controlled with glargine and aspart. The client becomes shaky, diaphoretic, and has slurred speech. What action should the school nurse take first? 1. Administer 1 tbs of honey 2. Give crackers with peanut butter 3. Inject 1 mg intramuscular glucagon 4. Provide an 8-oz glass of juice with 4 packs of sugar

1

A client is being monitored in the recovery room following a right adrenalectomy. The nurse notes a sudden increase in heart rate (HR) to 110/min and decrease in blood pressure (BP) from 140/80 mm Hg to 90/58 mm Hg. Which intervention is a priority? 1. Administer PRN dose of metoprolol intravenous (IV) push to keep HR <90 2. Give hydrocortisone intravenous (IV) push 3. Remove the dressing to assess for bleeding at the surgical site 4. Teach client signs and symptoms of adrenal insufficiency

2

During a screening clinic, the nurse performs a health assessment on several adult clients. Which finding by the nurse is most important to report to the primary health care provider? 1. Body mass index (BMI) of 23 kg/m2 2. Brownish skin thickening on the neck 3. Fasting total cholesterol of 180 mg/dL (4.7 mmol/L) 4. Round 3x3 mm pale pink mole

2

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy? 1. Assess how far the client can walk 2. Check sensation in fingers and toes 3. Inspect extremities for diabetic ulcers 4. Take the blood pressure sitting and standing

4

The nurse in an outpatient clinic receives a blood test report of moderately elevated thyroid-stimulating hormone (TSH) and markedly decreased T3 and T4 levels. Which signs and/or symptoms should be expected in the client's evaluation? Select all that apply 1. Cold intolerance 2. Constipation 3. Forgetfulness 4. Hair loss 5. Warm, moist skin 6. Weight loss

1,2,3,4

The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply. 1. Cold intolerance 2. Difficulty concentrating 3. Fever 4. Menstrual irregularity 5. Night sweats 6. Tachycardia

1,2,4

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider? 1. Fasting blood glucose 99 mg/dL (5.5 mmol/L) 2. Serum creatinine 2 mg/dL (177 µmol/L) 3. Serum potassium 3.9 mEq/L (3.9 mmol/L) 4. Serum sodium 140 mEq/L (140 mmol/L)

2

The nurse is assigned to care for a client who had a thyroidectomy 24 hours ago. On initial assessment, which finding requires the most immediate action by the nurse? 1. Calcium 8.8 mg/dL (2.20 mmol/L) 2. Heart rate 110/min 3. Laryngeal stridor 4. Pain rated 8 out of 10

3

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy. What will the nurse emphasize as most important to report immediately? 1. Elevated blood pressure 2. Heart rate irregularity 3. Low oxygen saturation 4. Noisy breathing

4

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume related to osmotic diuresis 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose 3. Ineffective breathing pattern related to the presence of metabolic acidosis 4. Ineffective health maintenance related to the inability to manage DM during illness

1

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy. Which intervention should the nurse implement? 1. Administer desmopressin 2. Assess fasting blood glucose 3. Institute fluid restriction 4. Place the client in the Trendelenburg position

1

An elderly client with hypothyroidism is brought to the emergency department for depressed mental status. The client lives alone but has not taken medications for several months or seen a health care provider. Which action should the nurse take first? Click on the exhibit button for additional information. Exhibit Vital signs Temperature 95 F (35 C) Blood pressure 90/50 mm Hg Heart rate 50/min Respirations 37/min O2 saturation 83% 1. Administer IV levothyroxine 2. Check serum thyroid-stimulating hormone, T3 and T4 3. Place a warming blanket on the client 4. Prepare for endotracheal intubation

4

The nurse assesses a client who had a thyroidectomy 8 hours ago. The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm. Which action is most important for the nurse to implement first? 1. Change the surgical dressing to assess for bleeding 2. Document the findings in the electronic medical record 3. Draw arterial blood gases 4. Obtain a serum calcium level

4

The nurse assesses a female client with a diagnosis of primary adrenal insufficiency (Addison's disease). The nurse recognizes which finding associated with the disease? 1. Bronze pigmentation of skin with patchy areas 2. Increased body or facial hair 3. Purplish or red striae on the abdomen 4. Supraclavicular fat pad

1

In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which actions should the nurse expect to implement? Select all that apply. 1. Administer potassium supplement when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L) 2. Discontinue insulin infusion when fingerstick blood glucose is <350 mg/dL (19.4 mmol/L) 3. Increase the insulin infusion rate when blood glucose level decreases 4. Monitor fingerstick or serum blood glucose every hour 5. Start infusion of dextrose 5% water when blood glucose is <250 mg/dL (13.9 mmol/L)

1,4,5

A client with type 1 diabetes mellitus is on intensive insulin therapy. The client is of the Islamic faith and insists on fasting during Ramadan. What is the most importantnursing action? 1. Advise the client of the risks of fasting when diabetic 2. Assess the client's clinical stability and glycemic control 3. Refer the client to the health care provider for adjustment of the insulin therapy 4. Refer the client to the registered dietitian for meal planning

2

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse give the client regarding this test? Select all that apply. 1. "A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag." 2. "Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." 3. "Only daytime urine should be collected in the container as cortisol levels are higher in the morning." 4. "Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder." 5. "You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

2,4,5

The breakfast trays arrive on the unit, and a newly admitted client with type 1 diabetes mellitus is hungry and wants to eat. The nurse reviews the vital signs, laboratory results,and medication administration record. Why does the nurse contact the health care provider before administering the client's 0700 medications? Click on the exhibit button for additional information. EXHIBIT Vital signs at 0600 Blood pressure 156/84 mm Hg Pulse 60/min & regular Respirations 16/min Laboratory results at 0630 Glucose 270 mg/dL (14.9 mmol/L) Potassium 3.6 mEq/L (3.6 mmol/L) Sodium 137 mEq/L (137 mmol/L) Allergies: None Medications Time Detemir: 7 units subcutaneously, twice a day 0700 and 2100 Hydrochlorothiazide: 25 mg orally, daily 0700 Potassium chloride: 40 mEq orally, daily 0700 Spironolactone: 50 mg orally, daily 0700 1. To question the detemir prescription 2. To question the spironolactone prescription 3. To report the serum glucose level 4. To report the serum potassium level

3

The home health nurse is visiting a client with diabetes who was recently discharged after a below-the-knee amputation. Which statement from the client's spouse indicates thatadditional teaching is needed? 1. "I hope my spouse's leg doesn't become red or swollen, because then we will have to take another trip to the hospital to get it checked out." 2. "My spouse hates poking the finger to check blood glucose, but it needs to get done so I help sometimes." 3. "My spouse just threw away all cigarettes in order to stop smoking." 4. "The wound specialist at the hospital taught me how to wrap my spouse's leg and even gave me extra supplies."

3

The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect? 1. Appetite has improved 2. Blood glucose is 110 mg/dL (6.1 mmol/L) 3. Urine output has decreased 4. Urine specific gravity is lower

3

The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client's risk for metabolic syndrome? 1. 27-year-old woman with triglycerides 210 mg/dL (2.4 mmol/L), blood pressure 128/82 mm Hg, and fasting blood glucose 98 mg/dL (5.4 mmol/L) 2. 45-year-old man with waist circumference 38 inches (96.6 cm), high-density lipoprotein (HDL) 49 mg/dL (1.3 mmol/L), and fasting blood glucose 118 mg/dL (6.6 mmol/L) 3. 55-year-old woman with waist circumference 37 inches (94 cm), triglycerides 190 mg/dL (2.2 mmol/L), and fasting blood glucose 120 mg/dL (6.7 mmol/L) 4. 82-year-old man with HDL 45 mg/dL (1.2 mmol/L), blood pressure 148/88 mm Hg, and fasting blood glucose 104 mg/dL (5.8 mmol/L).

3

A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply. 1. Administer dextrose 50 mg intravenous (IV) push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline Incorrect. Correct answer is 3,4,5

3,4,5

The nurse practicing in an out-patient clinic cares for a client recently diagnosed with hyperthyroidism. Which diet-related teaching should the nurse add to the client's plan of care? Select all that apply. 1. Emphasize the importance of a low-carbohydrate diet 2. Encourage the client to increase high-fiber foods in the diet 3. Include meals and snacks high in protein content 4. Teach avoidance of caffeine-containing liquids 5. Teach the client about consumption of a high-calorie diet of 4000-5000 calories/day

3,4,5

A client is admitted to the intensive care unit with suspected pheochromocytoma. The client's vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min. The client is sweating profusely and reports a severe headache. Which prescription should the nurse implement first? 1. Draw labs to assess electrolyte panel 2. Give acetaminophen 650 mg by mouth as needed for headache 3. Place a fan in the client's room 4. Start nitroprusside infusion at 0.5 mcg/kg/min

4

A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider? 1. Albumin of 3.0 g/dL (30 g/L) in a client with chronic hepatitis 2. B-type natriuretic peptide of 400 pg/mL (400 pmol/L) in a client with heart failure 3. Magnesium of 1.7 mEq/L (0.85 mmol/L) in a client with alcohol withdrawal 4. Sodium of 120 mEq/L (120 mmol/L) in a client with small cell lung cancer

4

The nurse assesses a 40-year-old client with acromegaly in an outpatient health clinic. Which new finding is most important to report to the health care provider? 1. Complaints of knee pain when walking 2. Dark leathery skin 3. Fasting blood glucose 126 mg/dL (7.0 mmol/L) 4. Presence of S3 and S4 heart sound

4

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first? 1. Insert an indwelling urinary catheter for accurate output calculation 2. Obtain serum potassium level results and report to the primary health care provider 3. Prepare an insulin drip for intravenous (IV) infusion as prescribed 4. Start an IV line and infuse normal saline as prescribed

4

The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Carpal tunnel syndrome 2. Diabetes mellitus 3. Sciatica 4. Small cell lung cancer

4

A client with type 2 diabetes mellitus is hospitalized for amputation of the toe. The diabetes is controlled with a morning dose of insulin glargine and lispro with meals daily. In the morning, the client's fingerstick glucose is 98 mg/dL (5.4 mmol/L) before breakfast. The breakfast tray arrives. What action should the nurse take? 1. Administer both insulins as prescribed 2. Hold both glargine and lispro insulin 3. Hold the glargine insulin 4. Hold the lispro insulin

1

A nurse is teaching a class on the dietary management of diabetes mellitus to a group of clients diagnosed with type 2 diabetes mellitus. The nurse knows that the client most likely to benefit from using advanced carbohydrate counting (ACC) for meal planning is: 1. The 20-year-old young adult on daily multiple injection therapy 2. The 34-year-old adult on a split mixed dose of insulin 3. The 40-year-old adult who controls type 2 diabetes mellitus with diet and exercise alone 4. The 50-year-old adult on an oral hypoglycemic agent

1

An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action? 1. Assess the client's level of orientation 2. Assess the insulin pump infusion site 3. Check the prescribed insulin pump settings 4. Consult the diabetic resource nurse or educator

1

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results? 1. "It is important for us to review the signs and symptoms of a hypoglycemic reaction." 2. "Let's review your diet, exercise, and medication regimen over the past 2-3 months." 3. "Please describe what you have eaten in the last 24-48 hours." 4. "You should fast for at least 8 hours prior to your morning blood work."

2

The nurse cares for a client with type 2 diabetes mellitus. The client is alert and oriented but also shaky, pale, and diaphoretic. The client's fingerstick blood glucose is 50 mg/dL (2.8 mmol/L). Which of the following is the best next step the nurse can take? 1. Administer dextrose 50 mg intravenous push 2. Give client 6 oz of orange juice or low-fat milk 3. Inject the client with glucagon 2 mg intramuscularly 4. Verify fingerstick blood glucose with serum blood draw

2

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1. Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis 4. Request prescription for potassium infusion

2

The nurse teaches proper foot care to a client with diabetes mellitus. Which statement by the client indicates that further teaching is needed? 1. "I will apply lanolin to my feet to prevent dry skin." 2. "I will make sure my flip flops are made of leather." 3. "I will not apply a heating pad directly to my feet." 4. "I will test the water with a thermometer before bathing."

2

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply. 1. Administer hydromorphone IV PRN for pain 2. Administer intravenous fluids 3. Insert a nasogastric tube for nasogastric suction 4. Maintain client in a supine position, with head of bed flat 5. Provide small, frequent, high-carbohydrate, high-calorie meals

1,2,3

The nurse educates a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which instruction(s) should the nurse include in the teaching plan? Select all that apply. 1. "A pregnancy test must be obtained prior to RAIU test administration." 2. "All jewelry or metal around the neck area should be removed before the RAIU test." 3. "Antithyroid medications should be held for 5-7 days before the RAIU test." 4. "Conscious sedation will be used to help with relaxation during the RAIU test." 5. "It is important to refrain from eating or drinking for at least 12 hours before the RAIU test."

1,2,3

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease. Which nursing action(s) should be included in the client's plan of care? Select all that apply. 1. Administer artificial tears to moisten the conjunctiva 2. If eyelids don't close during sleep, lightly tape them shut 3. Recommend the use of dark glasses to prevent irritation 4. Teach about the importance of smoking cessation 5. Teach avoidance of eye movement to prevent further damage

1,2,3,4

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply. 1. Blood glucose level >600 mg/dL (33.3 mmol/L) 2. History of type 2 diabetes 3. Kussmaul respirations 4. Neurological manifestations 5. Abdominal pain

1,2,4

The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included? Select all that apply. 1. Cut toenails straight across and file along the curves of the toes 2. Rub feet vigorously with a towel after bathing to ensure dryness 3. Use a mild foot powder on perspiring feet 4. Use cotton or lamb's wool to separate overlapping toes 5. Use an over-the-counter corn removal kit to remove corns or calluses

1,3,4

A client is suspected of having Graves' disease (hyperthyroidism). Which signs and/or symptoms are expected to be present in this client? Select all that apply. 1. Anxiety 2. Bradycardia 3. Dry skin 4. Heart palpitations 5. Protrusion of the eyeballs 6. Weight gain

1,4,5

A nurse is caring for a client who has Cushing syndrome due to adrenal tumor. Which assessment finding should the nurse anticipate in this client? Select all that apply. 1. Hirsutism 2. Hypotension 3. Serum potassium is 5.8 mEq/L 4. Serum sodium is 154 mEq/L 5. Truncal obesity

1,4,5

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction? 1. "I should avoid alcohol intake with this new medication." 2. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)." 3. "I should read the labels on all foods I eat, including those that say 'sugarless'." 4. "This medication will help me lose weight."

4

The nurse is assessing a group of clients in the community health clinic for risk factors of metabolic syndrome. Which clients exhibit a risk factor indicator of metabolic syndrome? Select all that apply. 1. Female with a low-density lipoprotein (LDL) level of 96 mg/dL (2.5 mmol/L) 2. Female with a waist circumference of 38 inches (96.5 cm) 3. Female with blood pressure of 148/90 mm Hg 4. Male with a fasting blood glucose of 124 mg/dL (6.9 mmol/L) 5. Male with a triglyceride level of 190 mg/dL (2.2 mmol/L)

2,3,4,5

The nurse assesses a client in an outpatient clinic with a new diagnosis of symptomatic primary hyperparathyroidism. Which client data should the nurse expect? Select all that apply 1. Diarrhea 2. Kidney stones 3. Osteoporosis 4. Perioral numbness 5. Polyuria

2,3,5

The nurse plans teaching for a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include in the teaching plan? Select all that apply. 1. Drowsiness is a common side effect; taking the dose at bedtime will make this less noticeable 2. Notify the health care provider if you become pregnant as the medication is harmful to the fetus 3. Notify the health care provider if you feel a fluttering or rapid heartbeat 4. Take the medication with a meal to prevent stomach upset 5. You will need to take this medication for the rest of your life

3,5

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply. 1. Client with a malignancy prescribed filgrastim has neutropenia 2. Client with acute osteomyelitis prescribed vancomycin has leukocytosis 3. Client with acute pancreatitis prescribed hydromorphone has an elevated lipase level 4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level

4,5

The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur. Which client information ismost important to report to the primary health care provider (PHCP)? 1. Blood pressure change from 128/80 mm Hg to 90/50 mm Hg 2. Development of a 1st-degree atrioventricular (AV) block on electrocardiogram (ECG) 3. Reports of right femur pain of 7 on a scale of 1-10 4. Vesicular breath sounds auscultated over the lung tissue

1

The nurse assesses a client with a diagnosis of Cushing syndrome. Which clinical manifestation(s) associated with this condition should the nurse expect? Select all that apply. 1. Hyperglycemia 2. Hypertension 3. Hyponatremia 4. Truncal obesity 5. Weight loss

1,2,4

When no changes are made to the diet or prescribed insulin, which client with type I diabetes mellitus does the nurse anticipate having the highest risk of developing hypoglycemia? 1. A 29-year-old with new onset of influenza 2. A 40-year-old experienced bicycle rider who adds 10 extra miles to his route 3. A 65-year-old with cellulitis in the right leg 4. A 72-year-old with emphysema who is taking prednisone

2

A client is admitted to the intensive care unit with diagnoses of a brain tumor complicated by transient diabetes insipidus. Which client data related to this complication should the nurse expect? Select all that apply. 1. Dark amber urine with sediment 2. High serum osmolality 3. Low urine specific gravity 4. Recent weight gain 5. Reports of excessive thirst

2,3,5

The nurse cares for a client admitted to the hospital due to confusion. The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s) should the nurse expect to implement? Select all that apply. 1. Fluid bolus (normal saline) 2. Fluid restriction 3. Salt restriction in the diet 4. Seizure precautions 5. Strict record of fluid intake and output

2,4,5

The nurse in the intensive care unit is caring for a client who underwent a transsphenoidal hypophysectomy to remove a pituitary adenoma. Which interventions should the nurse include in the client's care? Select all that apply. 1. Encourage coughing frequently to prevent pneumonia 2. Inspect the mouth and perform mouth care every 4 hours 3. Maintain the head of the bed in a flat position 4. Perform frequent neurological checks 5. Teach the client to not use a toothbrush for 10 days

2,4,5

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which assessment technique should the nurse use to check for complications in this client? 1. Ask client to place backs of the hands against each other to provide hyperflexion of the wrist while the elbows remain flexed 2. Instruct client to lie down and run the heel of one foot down the shin of the other leg 3. Perform Romberg test by asking the client to stand with eyes closed and feet together 4. Place blood pressure (BP) cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes

4

A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin. The client's spouse asks why insulin is needed as the client is not a diabetic. What is the most appropriate response by the nurse? 1. "It is common for critically ill clients to develop type II diabetes. We give insulin to keep the glucose level under control (<140 mg/dL [7.8 mmol/L])." 2. "The client was diabetic before, but you just didn't know it. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])." 3. "The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140-180 mg/dL (7.8-10.0 mmol/L)." 4. "This increase is common in critically ill clients and affects their ability to fight off infection. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])."

3

The nurse in the emergency department is caring for a client recently diagnosed with Graves' disease who was admitted following a motor vehicle accident. The nurse notes the vital signs shown in the exhibit. The nurse alerts the primary health care provider that the client may be experiencing which condition? Click on the exhibit button for additional information. EXHIBIT Vital signs Admission 1 hour 2 hours Temperature 97.7 F (36.5 C) 98.9 F (37.2 C) 101.3 F (38.5 C) Blood pressure 124/84 mm Hg 142/90 mm Hg 160/100 mm Hg Pulse 86/min 112/min 132/min Respirations 12/min 16/min 22/min O2 saturation 96% 94% 95% 1. Hypertensive crisis 2. Malignant hyperthermia 3. Serotonin syndrome 4. Thyroid storm

4