Final for med surg 2

7. A nurse assesses a client with Cushing's disease. Which assessment findings should the nurse correlate with this disorder? (Select all that apply.) a. Moon face b. Weight loss c. Hypotension d. Petechiae e. Muscle atrophy

ANS: A, D, E Clinical manifestations of Cushing's disease include moon face, weight gain, hypertension, petechiae, and muscle atrophy.

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition?

increased rate and depth of respiration

After a stroke, a patient has ataxia. What intervention is most appropriate to include on the patient's plan of care?

Ambulate only with a gait belt

A nurse plans care for a patient with hyperparathyroidism. Which intervention does the nurse include in this patient's plan of care? A. Instruct the unlicensed assistive personnel to strain the patient's urine for stones. B. Provide the patient with a soft-bristled toothbrush for oral care. C. Ask the patient to ambulate in the hallway twice a day. D. Use a lift sheet to assist the patient with position changes.

D. Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the patient, instead of pulling on the patient, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every patient will need to have urine strained. The priority is preventing injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for this patient.

A nurse cares for a patient with a deficiency of aldosterone. Which assessment finding would the nurse correlate with this deficiency?

Increased urine output

A patient in the intensive care unit is scheduled for a assessment, the nurse lumbar puncture (LP) today. On finds the patient breathing irregularty with one pupl fixed and dilated. What action by the nurse is best?

Notify the provider of the findings immeditely

A nurse evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value should the nurse assess first?

a. Posterior pituitary hormones b. Adrenal medulla hormone c. Anterior pituitary hormones d. Parathyroid hormone ANS: C Breast fluid and milk production are induced by the presence of prolactin, secreted from the anterior pituitary gland. The other hormones would not cause fluid secretion from the clients breast

After teaching a client with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will no longer need to limit my fluid intake after surgery." b. "I am glad no visible incision will result from this surgery." c. "I hope I can go back to wearing size 8 shoes instead of size 12." d. "I will wear slip-on shoes after surgery to limit bending over."

c. "I hope I can go back to wearing size 8 shoes instead of size 12."

. A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, I feel numbness and tingling around my mouth. What action should the nurse take? a. Offer mouth care. b. Loosen the dressing. c. Assess for Chvosteks sign. d. Ask the client orientation questions.

c. Assess for Chvostek's sign. ANS: C Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess the client further by testing for Chvostek's sign and Trousseau's sign. Then the nurse should notify the provider. Mouth care, loosening the dressing, and orientation questions do not provide important information to prevent complications of low calcium levels.

A nurse cares for a patient who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? A. Propranolol (Inderal) B. Epinephrine (Adrenalin) C. Levothyroxine sodium (Synthroid) D. Atropine sulfate

ANS: B The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Propranolol is a beta blocker and would be contraindicated for a client with bradycardia.

A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L. Which action should the nurse take first? a. Consult with the dietitian about increased dietary sodium. b. Restrict the client's fluid intake to 600 mL/day. c. Handle the client gently by using turn sheets for re-positioning. d. Instruct unlicensed assistive personnel to measure intake and output.

ANS: B With SIADH, clients often have dilutional hyponatremia. The client needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. Adding sodium to the client's diet will not help if he or she is retaining fluid and diluting the sodium. The client is not at increased risk for fracture, so gentle handling is not an issue. The client should be on intake and output; however, this will monitor only the client's intake, so it is not the best answer. Reducing intake will help increase the client's sodium.

A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first? a. Encourage range-of-motion exercises. b. Document the finding and monitor the client. c. Take vital signs, including temperature. d. Assess pain and administer pain medication.

Take vital signs, including temperature

A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first? A. Reassure the patient that the voice change is temporary. B. Place the patient in high-Fowler's position and apply oxygen. C. Contact the provider and prepare for intubation. D. Document the finding and assess the patient hourly.

Contact the provider and prepare for intubation.