Exam 4

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? 1. Hypotension and fever 2. Mental status changes and hypertension 3. Subnormal temperature and hypotension 4. Complaints of weakness and hypertension

1. Rationale: The nurse should be alert to signs and symptoms of adrenal insufficiency after adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes. The remaining options are incorrect.

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? 1. Fever and tachycardia 2. Pallor and tachycardia 3. Agitation and bradycardia 4. Restlessness and bradycardia

1. Rationale: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever with temperatures greater than 100°F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

1.2.3. Rationale: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

2. Rationale: Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? 1. Bradycardia 2. Flaccid paralysis 3. Tingling around the mouth 4. Absence of Chvostek's sign

3. Rationale: After thyroidectomy the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and in the fingertips, muscle twitching or spasms, palpitations or arrhythmias, and Chvostek's and Trousseau's signs. Bradycardia, flaccid paralysis, and absence of Chvostek's sign are not signs of hypocalcemia.

The nurse is creating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority? 1. Diarrhea 2. Nutrition 3. Aspiration 4. Deficient fluid volume

3. Rationale: Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places the client at risk for aspiration. Diarrhea and nutrition may be appropriate problems, but they are not of highest priority. Deficient fluid volume is not likely to occur in this client.

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3.4.5.6. Rationale: Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.

The nurse has documented the problem of body image distortion for a client with a diagnosis of Cushing's syndrome. The nurse identifies nursing interventions related to this problem and includes these interventions in the plan of care. Which nursing intervention is inappropriate? 1. Encourage the client's expression of feelings. 2. Assess the client's understanding of the disease process. 3. Encourage family members to share their feelings about the disease process. 4. Encourage the client to recognize that the body changes need to be dealt with.

4.Rationale: Encouraging the client to understand that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. The remaining options are appropriate because they address the client and family feelings regarding the disorder.

A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism? a. My sister has thyroid problems. b. I seem to feel the heat more than other people. c. Food just doesnt taste good without a lot of salt. d. I am always tired, even with 12 hours of sleep.

ANS: D Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep. Thyroid problems are not inherited. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hypothyroidism.

A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective? a. Thirst is recognized and fluid intake is appropriate. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3. d. Heart rate is 70 beats/min and regular.

ANS: D Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a clients heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic response to this medication.

A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first? a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Place the client in high-Fowlers position and apply oxygen. d. Contact the provider and prepare for intubation. .

ANS: D Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open

A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment? a. Stand in front of the client instead of behind the client. b. Ask the client to swallow after palpating the thyroid. c. Palpate the right lobe with the nurses left hand. d. Place the client in a sitting position with the chin tucked down.

ANS: D The client should be in a sitting position with the chin tucked down as the examiner stands behind the client. The nurse feels for the thyroid isthmus while the client swallows and turns the head to the right, and the nurse palpates the right lobe with the right hand. The technique is repeated in the opposite fashion for the left lobe.

The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. "Your weight is within normal limits. Continue maintaining with current lifestyle choices." b. "You are a little overweight. Cut down on calories and increase your activity, and you should be fine." c. "You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery." d. "You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

ANS: D This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify for surgical intervention until BMI reaches over 35.

The nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse instructs the client that which food item is a good dietary source of iron? 1. Oranges 2. Apricots 3. Egg whites 4. Refined white bread

2. Home History Help Calculator Study ModeQuestion 26 of 66QN: 3832 | ID: 2018 | file: Funds_3 Previous 26 Go Next Stop Bookmark Rationale Strategy Reference(s) Submit The nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse instructs the client that which food item is a good dietary source of iron?Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.

The nurse is creating a plan of care for a client receiving enteral feedings via a gastrostomy tube (G-tube). The nurse should plan to include which intervention in the plan of care? 1. Provide oral fluids 3 times per day. 2. Check around the stoma site for skin irritation. 3. Medicate with antidiarrheal medications every day. 4. Use sterile technique when administering the tube feedings.

2. Rationale: A G-tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. Generally, G-tubes are well tolerated and beneficial to clients on long-term enteral nutrition. Aspiration of stomach contents into the lungs can occur, and the client's head of the bed must be kept elevated. Because of the surgical incision, occasionally gastric contents leak out onto the client's skin. Gastric contents are highly acidic and can cause skin irritation. The skin irritation may lead to infection. The nurse must monitor the insertion site for skin irritation. Oral fluids are not generally a component of the plan of care because the client with a G-tube normally does not have the capability of swallowing. Although diarrhea may be a complication of the feedings, antidiarrheals are not administered daily. Aseptic, not sterile, technique is necessary when administering feedings.

The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? 1. Iron deficiency 2. Protein deficiency 3. Fatty acid deficiency 4. Vitamin K deficiency

1. Rationale: Brittle nails result from an iron deficiency. Protein deficiency leads to hair thinning and loss. Fatty acid deficiency can result in dermatitis, and vitamin K deficiency results in bruising.

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? 1. Dry skin 2. Thin, silky hair 3. Bulging eyeballs 4. Fine muscle tremors

1. Rationale: Myxedema is a deficiency of thyroid hormone. The client will present with a puffy, edematous face, especially around the eyes (periorbital edema), along with coarse facial features; dry skin; and dry, coarse hair and eyebrows. The remaining options are noted in the client with hyperthyroidism.

The nurse is providing dietary instructions to a client about food items that are high in niacin. Which food item should the nurse recommend as highest in niacin? 1. Poultry 2. Potatoes 3. Tomatoes 4. Strawberries

1. Rationale: Poultry, eggs, meats, and dairy products are high in niacin. Tomatoes, potatoes, and strawberries are high in ascorbic acid (vitamin C).

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Monitor daily weight. 2. Monitor intake and output. 3. Assess extremities for edema. 4. Maintain a high-sodium diet. 5. Maintain a low-potassium diet.

1.2.3. Rationale: The client with Cushing's syndrome and a problem of excess fluid volume should be on daily weights and intake and output and have extremities assessed for edema. He or she should be maintained on a high-potassium, low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water.

The nurse is providing home care instructions to the client with a diagnosis of Cushing's syndrome and prepares a list of instructions for the client. Which instructions should be included on the list? Select all that apply. 1. The signs and symptoms of hypoadrenalism 2. The signs and symptoms of hyperadrenalism 3. Instructions to take the medications exactly as prescribed 4. The importance of maintaining regular outpatient follow-up care 5. A reminder to read the labels on over-the-counter medications before purchase

1.2.3.4. Rationale: The client with Cushing's syndrome should be instructed to take the medications exactly as prescribed. The nurse should emphasize the importance of continuing medications, consulting with the health care provider (HCP) before purchasing any over-the-counter medications, and maintaining regular outpatient follow-up care. The nurse also should instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism.

Which actions should the nurse include when caring for a client with continuous tube feedings through a nasogastric (NG) tube? Select all that apply. 1. Check the residual every 4 hours. 2. Check for placement every 4 hours. 3. Hang a new feeding bag every 72 hours. 4. Check skin integrity at the site of NG tube insertion. 5. Check for placement before administering medications.

1.2.4.5. Rationale: A feeding bag and tubing should be changed every 24 hours (or per agency protocol) to reduce risk of bacterial contamination. Placement and residual should be checked at least every 4 hours during administration of continuous tube feedings and prior to giving medications through the tube. Agency policy for technique for assessment of tube placement should be followed. Skin integrity should be assessed at the site of NG tube insertion.

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1.2.4.5. Rationale: Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

A nursing student is caring for a client who has been admitted to the hospital with malnutrition. The nursing instructor determines that the student has made a correct assessment of malnutrition consequences if the student documents which noted findings? Select all that apply. 1. Cachexic 2. Lethargic 3. Lean extremities 4. Intolerant to heat 5. Dry, flaking skin 6. Poor wound healing

1.2.5.6. Rationale: Some common findings of severe malnutrition in adults include the following: lethargy; cachexia; dry, flaking skin; and poor wound healing. Edema, not lean extremities, and intolerance to cold, not heat, are also present.

A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. 1. Hypotension 2. Leukocytosis 3. Hyperkalemia 4. Hypercalcemia 5. Hypernatremia

1.3. Rationale: In Addison's disease, also known as adrenal insufficiency, destruction of the adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal insufficiency, occurs when there is extreme physical or emotional stress and lack of sufficient adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the catecholamines epinephrine and norepinephrine. Hypotension occurs when vascular tone is decreased and blood vessels cannot respond to epinephrine and norepinephrine. The role of aldosterone in the body is to support the blood pressure by holding salt and water and excreting potassium. When there is insufficient aldosterone, salt and water are lost and potassium builds up; this leads to hypotension from decreased vascular volume, hyponatremia, and hyperkalemia. The remaining options are not associated with Addisonian crisis.

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. 1. Initiate an infusion of 3% NaCl. 2. Administer intravenous furosemide. 3. Restrict fluids to 800 mL over 24 hours. 4. Elevate the head of the bed to high Fowler's. 5. Administer a vasopressin antagonist as prescribed.

1.3.5. Rationale: Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia. Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). An intravenous (IV) infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as prescribed and an infusion pump must be used. Fluid restriction is a useful strategy aimed at correcting dilutional hyponatremia. Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide may be used to treat extravascular volume and dilutional hyponatremia in SIADH, but it is only safe to use if the serum sodium is at least 125 mEq/L (125 mmol/L). When furosemide is used, potassium supplementation should also occur and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the client with SIADH. Maximizing venous return helps to avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed.

The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor for changes in mentation. 2. Encourage an intake of low-protein foods. 3. Encourage an intake of low-sodium foods. 4. Encourage fluid intake of at least 3000 mL per day. 5. Monitor vital signs, skin turgor, and intake and output.

1.4.5. Rationale: The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase intake of sodium, protein, and complex carbohydrates and fluids. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Mentation, vital signs, skin turgor and intake and output should be monitored for signs of fluid volume deficit.

A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. The client expresses concern about performing this procedure at home. What is the nurse's best response? 1. "Maybe a friend will do the feeding for you." 2. "Tell me more about your concerns about going home." 3. "Do you want to stay in the hospital a few more days?" 4. "Have you discussed your feelings with your family and doctor?"

2. Rationale: A client often has fears about leaving the secure environment of a health care facility. This client has a specific fear about not being able to handle tube feedings at home. An open communication statement such as "Tell me more about . . ." often leads to valuable information about the client and his or her concerns. Options 1 and 4 are nontherapeutic responses because they place the client's issues on hold. Option 3 is beyond the scope of practice for the nurse to implement and may not be necessary.

The nurse is caring for a client with a diagnosis of celiac disease. The nurse recognizes that client teaching has been effective when the client makes which statement? 1. "I can eat whatever I want." 2. "I will eat rice cereal for breakfast." 3. "I will eat beef barley soup for lunch." 4. "I will eat only wheat bread for a snack."

2. Rationale: A client with celiac disease should be instructed to avoid gluten-containing products such as wheat, barley, oats, and rye.

The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention should the nurse include in the plan of care? 1. Maintain a supine position. 2. Monitor neck circumference every 4 hours. 3. Maintain a pressure dressing on the operative site. 4. Encourage deep-breathing exercises and vigorous coughing exercises.

2. Rationale: After thyroidectomy, neck circumference is monitored every 4 hours to assess for the occurrence of postoperative edema. The client should be placed in an upright position to facilitate air exchange. A pressure dressing is not placed on the operative site because it may restrict breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. The nurse should assist the client with deep-breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk 2. Oranges 3. Bananas 4. Chicken

2. Rationale: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

The nurse is providing dietary instructions to a client with a diagnosis of hyperphosphatemia. The nurse determines that the client understands the instructions if the client states the importance of eliminating which item from the diet? 1. Tea 2. Fish 3. Coffee 4. Grape juice

2. Rationale: Clients with hyperphosphatemia should avoid foods that are naturally high in phosphates. These include fish, eggs, milk products, vegetables, whole grains, and carbonated beverages. Tea, coffee, and grape juice are not high in phosphates.

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? 1. Dry skin 2. Bulging eyeballs 3. Periorbital edema 4. Coarse facial features

2. Rationale: Hyperthyroidism is clinically manifested by goiter (increase in the size of the thyroid gland) and exophthalmos (bulging eyeballs). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair and thin skin; infrequent blinking; and a staring appearance.

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement.

2. Rationale: Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.

A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? 1. "Don't be concerned; this problem can be covered with clothing." 2. "Usually these physical changes slowly improve following treatment." 3. "This is permanent, but looks are deceiving and are not that important." 4. "Try not to worry about it; there are other things to be concerned about."

2. Rationale: The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. All other options are not therapeutic responses.

The nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which intervention should the nurse implement to determine the effectiveness of the tube feedings? 1. Use a calorie count. 2. Obtain a daily weight. 3. Evaluate intake and output. 4. Monitor serum protein level.

2. Rationale: The most accurate measurement of the effectiveness of nutritional management of the client is through the use of daily weighing. These weight checks should be done every day at the same time (preferably early morning), in the same clothes, and using the same scale. Options 1, 3, and 4 assist in measuring nutrition and hydration status. However, the effectiveness of the diet is measured by maintenance of body weight.

The nurse is giving a presentation on good nutrition to a group of teenage mothers. Which level of prevention is the nurse implementing? 1. Basic level 2. Primary level 3. Secondary level 4. Tertiary level

2. Rationale: The primary level is focused on prevention, and educational classes are a form of prevention. The secondary level is a screening level that entails such procedures as vision screening, mammography, or similar screening tests. The tertiary level is focused on rehabilitation skills. There is no basic level of prevention.

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

2. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?Rationale: After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

The nurse is explaining the process of bariatric surgery to a severely obese client who has attended a medically supervised weight loss program for approximately 6 months. The client is considering this procedure. What are some conditions that may interfere with a client's commitment to lifelong behavioral changes and that may lead to poor surgical outcomes? Select all that apply. 1. Anxiety 2. Untreated depression 3. Binge eating disorders 4. Drug and alcohol abuse 5. Lack of family resources 6. Inability to comply with nutritional recommendations

2.3.4.6. Rationale: Conditions that can lead to poor bariatric surgical outcomes include untreated depression, binge eating disorders, drug and alcohol abuse, and an inability to comply with nutritional recommendations. Lack of family resources and anxiety do not affect bariatric surgical outcomes.

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. 1. Anxiety 2. Leukocytosis 3. Chvostek's sign 4. Urinary output of 800 mL/hour 5. Clear drainage on nasal dripper pad

2.4.5. Rationale: Acromegaly results from excess secretion of growth hormone, usually caused by a benign tumor on the anterior pituitary gland. Treatment is surgical removal of the tumor, usually with a sublingual transsphenoidal complete or partial hypophysectomy. The sublingual transsphenoidal approach is often through an incision in the inner upper lip at the gum line. Transsphenoidal surgery is a type of brain surgery and infection is a primary concern. Leukocytosis, or an elevated white count, may indicate infection. Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy. In diabetes insipidus there is decreased secretion of antidiuretic hormone and clients excrete large amounts of dilute urine. Following transsphenoidal surgery, the nasal passages are packed and a dripper pad is secured under the nares. Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid leak. The surgeon should be notified and the drainage should be tested for glucose. A cerebrospinal fluid leak increases the postoperative risk of meningitis. Anxiety is a nonspecific finding that is common to many disorders. Chvostek's sign is a test of nerve hyperexcitability associated with hypocalcemia and is seen as grimacing in response to tapping on the facial nerve. Chvostek's sign has no association with complications of sublingual transsphenoidal hypophysectomy.

The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? 1. A client with hypothyroidism 2. A client with Graves' disease who is having surgery 3. A client with diabetes mellitus scheduled for a diagnostic test 4. A client with diabetes mellitus scheduled for debridement of a foot ulcer

2.Rationale: Thyrotoxicosis usually is seen in clients with Graves' disease in whom the symptoms are precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, delivery, or major surgery. It also must be recognized as a potential complication after thyroidectomy. The client conditions in the remaining options are not associated with thyrotoxicosis

A nurse is providing home care instructions to a client with a diagnosis of Addison's disease. Which statement by the client indicates a need for further instruction? 1. "I need to wear a MedicAlert bracelet." 2. "I need to purchase a travel kit that contains cortisone." 3. "I will need to take daily medications until my symptoms decrease." 4. "I need an increased dose of glucocorticoid medication during stressful minor illnesses."

3. Rationale: Client teaching includes the need for lifelong daily medications. The client also is instructed to carry or wear a medical identification card or bracelet. A travel kit will need to be purchased. It should contain oral cortisone along with intramuscular preparations for self-injection and intravenous vials for emergency injection by a health care provider. Increased glucocorticoid dosage during stressful minor illnesses will be necessary.

The nurse is evaluating a client's ability to select food items for a low-potassium diet. Which food item, if selected by the client, would indicate an understanding of this diet? 1. Spinach 2. Strawberries 3. Cranberry juice 4. Honeydew melon

3. Rationale: Spinach, strawberries, and honeydew melon are high-potassium foods and average 10 mEq per serving. Cranberry juice is low in potassium and averages 5 mEq per serving.

The nurse has determined that an unconscious client is at risk for nutritional problems. Which outcome indicates to the nurse that the goals have not yet been fully met? 1. Stable weight 2. Intake equaling output 3. Total protein concentration of 4.5 g/dL (45 g/L) 4. Blood urea nitrogen (BUN) level of 20 mg/dL (7.1 mmol/L)

3. Rationale: The normal total protein level is 6.4 to 8.3 g/dL (64 to 83 g/L). The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Expected outcomes for nutritional problems in an unconscious client include stable weight, intake equaling output, evidence of wound healing, and normal BUN, total protein, and hemoglobin levels. The only abnormal finding in the options is the protein level.

The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's (HCP's) prescriptions, if noted on the record, would indicate the need for clarification? 1. Assess vital signs and neurological status. 2. Instruct the client to avoid blowing his nose. 3. Apply a loose dressing if any clear drainage is noted. 4. Instruct the client about the need for a MedicAlert bracelet.

3. Rationale: The nurse should observe for clear nasal drainage; constant swallowing; and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted after this procedure, the HCP needs to be notified. Therefore, clarification is needed regarding application of a loose dressing. The remaining options indicate appropriate postoperative interventions

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

3. Rationale: Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? 1. A platelet count of 200,000 mm3 (200 × 109/L) 2. A blood glucose level of 110 mg/dL (6.28 mmol/L) 3. A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) 4. A white blood cell (WBC) count of 6000 mm3 (6 × 109/L)

3. The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client?Rationale: The client with Cushing's syndrome experiences hypokalemia, hyperglycemia, an elevated WBC count, and elevated plasma cortisol and adrenocorticotropic hormone levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids in the body. The laboratory values listed in the remaining options would not be noted in the client with Cushing's syndrome.

The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. 1. Provide a warm environment for the client. 2. Instruct the client to consume a low-fat diet. 3. A thyroid-releasing inhibitor will be prescribed. 4. Encourage the client to consume a well-balanced diet. 5. Instruct the client that thyroid replacement therapy will be needed. 6. Instruct the client that episodes of chest pain are expected to occur.

3.4. Rationale: The clinical manifestations of hyperthyroidism are the result of increased metabolism caused by high levels of thyroid hormone. Interventions are aimed at reduction of the hormones and measures to support the signs and symptoms related to an increased metabolism. The client often has heat intolerance and requires a cool environment. The nurse encourages the client to consume a well-balanced diet because clients with this condition experience increased appetite. Iodine preparations are used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. Thyroid replacement is needed for hypothyroidism. The client would notify the health care provider if chest pain occurs because it could be an indication of an excessive medication dose.

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 5. Inform the client that iodine preparations will be prescribed to treat the disorder. 6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

3.4.6. Rationale: The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the HCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone.

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? 1. Agitation 2. Diaphoresis 3. Restlessness 4. Severe abdominal pain

4. Rationale: Addisonian crisis is a serious life-threatening response to acute adrenal insufficiency that most commonly is precipitated by a major stressor. The client in addisonian crisis may demonstrate any of the signs and symptoms of Addison's disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure. The remaining options do not identify clinical manifestations associated with addisonian crisis.

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client? 1. Infertility 2. Gynecomastia 3. Sexual dysfunction 4. Body image changes

4. Rationale: Because of the location of the incision in the neck area, many clients are afraid of thyroid surgery for fear of having a visible large scar postoperatively. Having all or part of the thyroid gland removed will not cause the client to experience gynecomastia. Sexual dysfunction and infertility could occur if the entire thyroid is removed and the client is not placed on thyroid replacement medications.

The nurse is providing dietary instructions to a client about food items that are high in vitamin C. Which food item does the nurse recommend as being highest in vitamin C? 1. Milk 2. Eggs 3. Liver 4. Cabbage

4. Rationale: Cabbage, tomatoes, potatoes, and strawberries are some of the foods that are high in vitamin C. Milk contains vitamins A and D and some B vitamins. Eggs contain B vitamins. Liver contains vitamins B6 (pyridoxine), B9 (folic acid), and K.

A client has been on total parenteral nutrition (TPN) for 8 weeks at home. The health care provider prescribes that the TPN be weaned by 50 mL per hour per day until discontinued. The client asks the nurse why the TPN cannot just be stopped. The nurse explains that unless the TPN infusions are tapered gradually, the client is at risk for developing which complication? 1. Dehydration 2. Hypokalemia 3. Hypernatremia 4. Hypoglycemia

4. Rationale: Clients receiving TPN are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rate is tapered downward. Before discontinuation of TPN, the body must adjust to the lowered glucose levels. If the TPN is suddenly withdrawn, the client could experience rebound hypoglycemia. Options 1, 2, and 3 are not associated with the discontinuation of the TPN.

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The health care provider prescribes an enteral tube feeding of a standard formula to run at 40 mL/hour. A nursing student is assigned to care for the client, and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which statement, if made by the student, indicates an understanding of this dietary treatment? 1. "Enteral tube feedings frequently cause sepsis." 2. "Enteral feedings should be refrigerated until just before use." 3. "The caloric value of enteral feedings is generally 5 to 10 calories per milliliter." 4. "Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."

4. Rationale: Enteral nutrition includes offering nutrients by mouth, nasogastric tube, gastrostomy tubes, or percutaneous endoscopic gastrostomy. The common element with these methods of delivery is the fact that the client must have normal gastrointestinal (GI) digestive capabilities. If the client does not have a normal GI tract, other methods of nutrient delivery must be sought, such as parenteral nutrition. Enteral tube feedings may cause aspiration pneumonia from regurgitation of formula into the lungs; however, they generally are not associated with sepsis. Enteral tube feedings should be given at room temperature to avoid problems with diarrhea. The caloric value of most standard enteral feeding formulas is 1 to 2 calories/mL.

The nurse is providing a dietary session to a group of clients about the vitamin content of various foods. The nurse should tell the clients that which food item is highest in vitamin A? 1. Eggs 2. Milk 3. Tomatoes 4. Green leafy vegetables

4. Rationale: Green leafy vegetables are a good source of vitamin A, whereas milk is high in vitamin D content. Eggs are high in vitamin B complex, and tomatoes are high in vitamin C.

The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? 1. "I need to eat foods high in potassium." 2. "I need to drink at least 2 to 3 L of fluid daily." 3. "I need to eat small, frequent meals and snacks if nauseated." 4. "I need to increase my intake of dietary items that are high in calcium."

4. Rationale: The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption of calcium. Dietary restriction of calcium may be used as a component of therapy. The client should eat foods high in potassium, especially if the client is taking furosemide. Drinking 2 to 3 L of fluid daily and eating small, frequent meals and snacks if nauseated are appropriate instructions for the client.

A client is being seen in the clinic for symptoms of hyperinsulinism. The nurse provides information to the client regarding dietary measures for the condition. Which diet would be most appropriate to suggest to the client? 1. Low-fiber, high-fat diet 2. Limiting food intake to 2 meals per day 3. Large amounts of carbohydrates between low-protein meals 4. Small, frequent meals with protein, fat, and carbohydrates at each meal

4. Rationale: The definition of hyperinsulinism is an excessive insulin secretion in response to consuming carbohydrate-rich foods. This leads to hypoglycemia. It is often treated with a diet that provides for limited stimulation of the pancreas. Carbohydrates can produce a rapid rise in blood glucose levels. However, carbohydrates are necessary in the diet. Proteins do not stimulate insulin secretion. Fats are needed in the diet to provide calories. The best diet for hyperinsulinism will contain proteins and fats whenever carbohydrates are consumed. Diets high in soluble fiber also may be beneficial.

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which should the nurse expect to note on assessment of the client? 1. Skin atrophy 2. The presence of sunken eyes 3. Drooping on 1 side of the face 4. A rounded "moonlike" appearance to the face

4. Rationale: With excessive secretion of adrenocorticotropic hormone (ACTH) and chronic corticosteroid use, the person with Cushing's syndrome develops a rounded moonlike face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheek, and chin. The remaining options are not associated with the assessment findings in Cushing's syndrome.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? 1. Nuts and milk 2. Coffee and tea 3. Cooked rolled oats and fish 4. Oranges and dark green leafy vegetables

4. Rationale: Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.

A nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which assessment finding should alert the nurse to a side effect of this therapy? a. Blurred and double vision b. Increased thirst and urination c. Profuse nausea and diarrhea d. Decreased attention and insomnia

ANS: B Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. This manifests with increased thirst and urination. Lithium has no effect on vision, gastric upset, or level of consciousness.

During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

ANS: A A BMI of 25 to 29.9 is in the overweight range. A BMI of <18.5 is in the underweight range. A BMI of 30 to 34.9 is obesity class I, a BMI of 35 to 39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19 to 24 is in the normal range.

13. While assessing a client with Graves disease, the nurse notes that the clients temperature has risen 1 F. Which action should the nurse take first? a. Turn the lights down and shut the clients door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the clients apical-radial pulse deficit. d. Administer a dose of acetaminophen (Tylenol).

ANS: A A temperature increase of 1 F may indicate the development of thyroid storm, and the provider needs to be notified. But before notifying the provider, the nurse should take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and Tylenol is not needed because the temperature increase is due to thyroid activity.

A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency? a. Increased urine output b. Vasoconstriction c. Blood glucose of 98 mg/dL d. Serum sodium of 144 mEq/L

ANS: A Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia.

A nurse teaches a client with a cortisol deficiency who is prescribed prednisone (Deltasone). Which statement should the nurse include in this clients instructions? a. You will need to learn how to rotate the injection sites. b. If you work outside in the heat, you may need another drug. c. You need to follow a diet with strict sodium restrictions. d. Take one tablet in the morning and two tablets at night.

ANS: B Steroid dosage adjustment may be needed if the client works outdoors and might be difficult, especially in hot weather, when the client is sweating a great deal more than normal. Clients take prednisone orally, have no need for a salt restriction, and usually start the regimen with two tablets in the morning and one at night.

During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth

ANS: A Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin deficiency. Inflammation of peripheral nerves (neuropathy) and numbness and tingling in extremities (paresthesia) are manifestations of a thiamin deficiency. Fissures of the mouth (cheilosis) and inflammation of the mouth (stomatitis) are manifestations of a pyridoxine deficiency.

A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider? a. Heart rate of 50 beats/min b. Respiratory rate of 18 breaths/min c. Oxygenation saturation of 92% d. Blood pressure of 144/69 mm Hg

ANS: A Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other vital signs are within normal limits and do not indicate a negative response to the medication.

A nurse assesses a client diagnosed with adrenal hypofunction. Which client statement should the nurse correlate with this diagnosis? a. I have a terrible craving for potato chips. b. I cannot seem to drink enough water. c. I no longer have an appetite for anything. d. I get hungry even after eating a meal.

ANS: A The nurse correlates a clients salt craving with adrenal hypofunction. Excessive thirst is related to diabetesinsipidus or diabetes mellitus. Clients who have hypothyroidism often have a decrease in appetite. Excessive hunger is associated with diabetes mellitus.

A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.) a. Excessive thyroid-stimulating hormone Increased bone formation b. Excessive melanocyte-stimulating hormone Darkening of the skin c. Excessive parathyroid hormone Synthesis and release of corticosteroids d. Excessive antidiuretic hormone Increased urinary output e. Excessive adrenocorticotropic hormone Increased bone resorption

ANS: A, B Thyroid-stimulating hormone targets thyroid tissue and stimulates the formation of bone. Melanocytestimulating hormone stimulates melanocytes and promotes pigmentation or the darkening of the skin. Parathyroid hormone stimulates bone resorption. Antidiuretic hormone targets the kidney and promotes water reabsorption, causing a decrease in urinary output. Adrenocorticotropic hormone targets the adrenal cortex and stimulates the synthesis and release of corticosteroids.

A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.) a. Hormones may travel long distances to get to their target tissues. b. Continued hormone activity requires continued production and secretion. c. Control of hormone activity is caused by negative feedback mechanisms. d. Most hormones are stored in the target tissues for use later. e. Most hormones cause target tissues to change activities by changing gene activity.

ANS: A, B, C Hormones are secreted by endocrine glands and travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the bodys needs, and continued hormone activity requires continued production and secretion. Control is maintained via negative feedback. Hormones are not stored for later use, and they do not alter genetic activity.

A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the clients level of consciousness has decreased. Which actions should the nurse take? (Select all that apply.) a. Infuse intravenous fluids. b. Cover the client with warm blankets. c. Monitor blood pressure every 4 hours. d. Maintain a patent airway. e. Administer oral glucose as prescribed.

ANS: A, B, D A client with hypothyroidism and an acute illness is at risk for myxedema coma. A decrease in level of consciousness is a symptom of myxedema. The nurse should infuse IV fluids, cover the client with warm blankets, monitor blood pressure every hour, maintain a patent airway, and administer glucose intravenously as prescribed.

A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for hypopituitarism? (Select all that apply.) a. A 20-year-old female with benign pituitary tumors b. A 32-year-old male with diplopia c. A 41-year-old female with anorexia nervosa d. A 55-year-old male with hypertension e. A 60-year-old female who is experiencing shock f. A 68-year-old male who has gained weight recently

ANS: A, C, D, E Pituitary tumors, anorexia nervosa, hypertension, and shock are all conditions that can cause hypopituitarism. Diplopia is a manifestation of hypopituitarism, and weight gain is a manifestation of Cushings disease and syndrome of inappropriate antidiuretic hormone. They are not risk factors for hypopituitarism.

A nurse assesses a client with anterior pituitary hyperfunction. Which clinical manifestations should the nurse expect? (Select all that apply.) a. Protrusion of the lower jaw b. High-pitched voice c. Enlarged hands and feet d. Kyphosis e. Barrel-shaped chest f. Excessive sweating

ANS: A, C, D, E, F Anterior pituitary hyperfunction typically will cause protrusion of the lower jaw, deepening of the voice, enlarged hands and feet, kyphosis, barrel-shaped chest, and excessive sweating.

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this clients teaching? (Select all that apply.) a. Increased carbohydrates b. Decreased fats c. Increased calorie intake d. Supplemental vitamins e. Increased proteins

ANS: A, C, E The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. There is no need to decrease fat intake or take supplemental vitamins.

A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.) a. Thyroid-stimulating hormone b. Vasopressin c. Follicle-stimulating hormone d. Calcitonin e. Growth hormone

ANS: A, C, E Thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone all are secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary gland. Calcitonin is secreted from the thyroid gland.

A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this clients education? (Select all that apply.) a. Do not share utensils, plates, and cups with anyone else. b. You can play with your grandchildren for 1 hour each day. c. Eat foods high in vitamins such as apples, pears, and oranges. d. Wash your clothing separate from others in the household. e. Take a laxative 2 days after therapy to excrete the radiation.

ANS: A, D, E A client who is prescribed an unsealed radioactive isotope should be taught to not share utensils, plates, and cups with anyone else; to avoid contact with pregnant women and children; to avoid eating foods with cores or bones, which will leave contaminated remnants; to wash clothing separate from others in the household and run an empty cycle before washing other peoples clothing; and to take a laxative on days 2 and 3 after receiving treatment to help excrete the contaminated stool faster.

A nurse assesses a client with Cushings 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 Cushings disease include moon face, weight gain, hypertension, petechiae, and muscle atrophy.

An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome

ANS: A, D, E, F Type 1 diabetes and celiac disease are more common in Northern European heritage.

The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient's son uses a marked pillbox to set up the patient's medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.

ANS: B A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older patient would have friends who have died.

After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional instruction? a. I may need calcium replacement after surgery. b. After surgery, I wont need to take thyroid medication. c. Ill need to take thyroid hormones for the rest of my life. d. I can receive pain medication if I feel that I need it.

ANS: B After the client undergoes a thyroidectomy, the client must be given thyroid replacement medication for life. He or she may also need calcium if the parathyroid is damaged during surgery, and can receive pain medication postoperatively.

After teaching a client who is recovering from an endoscopic trans-nasal hypophysectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will wear dark glasses to prevent sun exposure. b. Ill keep food on upper shelves so I do not have to bend over. c. I must wash the incision with peroxide and redress it daily. d. I shall cough and deep breathe every 2 hours while I am awake. .

ANS: B After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist and should not bear down, cough, or lie flat. With this approach, there is no incision to clean and dress. Protection from sun exposure is not necessary after this procedure

A nurse cares for a client newly diagnosed with Graves disease. The clients mother asks, I have diabetes mellitus. Am I responsible for my daughters disease? How should the nurse respond? a. The fact that you have diabetes did not cause your daughter to have Graves disease. No connection is known between Graves disease and diabetes. b. An association has been noted between Graves disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves disease. c. Graves disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes mellitus. d. Unfortunately, Graves disease is associated with diabetes, and your diabetes could have led to your daughter having Graves disease.

ANS: B An association between autoimmune diseases such as rheumatoid arthritis and diabetes mellitus has been noted. The predisposition is probably polygenic, and the mothers diabetes did not cause her daughters Graves disease. The other statements are inaccurate.

14. A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this clients teaching to decrease injury? a. Drink at least 2 liters of fluids each day. b. Walk around the neighborhood for daily exercise. c. Bathe your perineal area twice a day. d. You should check your blood glucose before meals.

ANS: B An older adult client with decreased production of estrogen is at risk for decreased bone density and fractures. The nurse should encourage the client to participate in weight-bearing exercises such as walking. Drinking fluids and performing perineal care will decrease vaginal drying but not decrease injury. Older adults often have a decreased glucose tolerance, but this is not related to a decrease in estrogen.

A nurse assesses clients for potential endocrine disorders. Which client is at greatest risk for hyperparathyroidism? a. A 29-year-old female with pregnancy-induced hypertension b. A 41-year-old male receiving dialysis for end-stage kidney disease c. A 66-year-old female with moderate heart failure d. A 72-year-old male who is prescribed home oxygen therapy

ANS: B Clients who have chronic kidney disease do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, and this triggers overstimulation of the parathyroid glands. Pregnancy-induced hypertension, moderate heart failure, and home oxygen therapy do not place a client at higher risk for hyperparathyroidism.

A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone? a. A 36-year-old female who has used oral contraceptives for 5 years b. A 42-year-old male who experienced head trauma 3 years ago c. A 55-year-old female with a severe allergy to shellfish and iodine d. A 64-year-old male with adult-onset diabetes mellitus

ANS: B Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition.

A nurse cares for a male client with hypopituitarism who is prescribed testosterone hormone replacement therapy. The client asks, How long will I need to take this medication? How should the nurse respond? a. When your blood levels of testosterone are normal, the therapy is no longer needed. b. When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever. c. When your sperm count is high enough to demonstrate fertility, you will no longer need this therapy. d. With age, testosterone levels naturally decrease, so the medication can be stopped when you are 50 years old.

ANS: B Testosterone therapy is initiated with high-dose testosterone derivatives and is continued until virilization is achieved. The dose is then decreased, but therapy continues throughout life. Therapy will continue throughout life; therefore, it will not be discontinued when blood levels are normal, at the age of 50 years, or when sperm counts are high.

A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client? a. Atropine sulfate b. Levothyroxine sodium (Synthroid) c. Propranolol (Inderal) d. Epinephrine (Adrenalin)

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 clients 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 clients 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 clients 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 clients intake, so it is not the best answer. Reducing intake will help increase the clients sodium.

A nurse teaches a client with Cushings disease. Which dietary requirements should the nurse include in this clients teaching? (Select all that apply.) a. Low calcium b. Low carbohydrate c. Low protein d. Low calories e. Low sodium

ANS: B, D, E The client with Cushings disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of carbohydrates and total calories to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Clients are encouraged to restrict their sodium intake moderately. Clients often have bone density loss and need more calcium. Increased protein intake will help decrease muscle loss.

A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this clients plan of care? a. Monitor the clients intravenous site every shift. b. Administer acetaminophen (Tylenol) for fever. c. Ensure that working suction equipment is in the room. d. Assess the clients vital signs every 4 hours.

ANS: C A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this emergency situation, maintaining an airway is a priority. The nurse should ensure that suction equipment is available in the clients room because it may be needed if myxedema coma develops. The other interventions are necessary for any client with pneumonia, but having suction available is a safety feature for this client.

A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take first? a. Keep the head of the bed flat and the client supine. b. Instruct the client to cough, turn, and deep breathe. c. Report clear or light yellow drainage from the nose. d. Apply petroleum jelly to lips to avoid dryness.

ANS: C A light yellow drainage or a halo effect on the dressing is indicative of a cerebrospinal fluid leak. The client should have the head of the bed elevated after surgery. Although deep breathing is important postoperatively, coughing should be avoided to prevent cerebrospinal fluid leakage. Although application of petroleum jelly to the lips will help with dryness, this instruction is not as important as reporting the yellowish drainage.

After teaching a client with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the clients 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.

ANS: C Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible. It will be appropriate for the client to drink as needed postoperatively and avoid bending over. The client can be reassured that the incision will not be visible.

When teaching a patient with a family history of hypertension about health promotion, the nurse describes blood pressure screening as which type of prevention? a. Illness b. Primary c. Secondary d. Tertiary

ANS: C Blood pressure screening is considered secondary prevention. It is a measure designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Illness prevention is considered primary prevention. Primary prevention measures are those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Tertiary prevention measures are those that minimize the effects of disease and disability.

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 hormones 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

A nurse plans care for a client with Cushings disease. Which action should the nurse include in this clients plan of care to prevent injury? a. Pad the siderails of the clients bed. b. Assist the client to change positions slowly. c. Use a lift sheet to change the clients position. d. Keep suctioning equipment at the clients bedside.

ANS: C Cushings syndrome or disease greatly increases the serum levels of cortisol, which contributes to excessive bone demineralization and increases the risk for pathologic bone fracture. Padding the siderails and assisting the client to change position may be effective, but these measures will not protect him or her as much as using a lift sheet. The client should not require suctioning.

During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein

ANS: C Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency have been identified, such as pyridoxine and thiamine. Protein deficiency causes decreased pigmentation and lackluster hair.

A nurse cares for a client who has hypothyroidism as a result of Hashimotos thyroiditis. The client asks, How long will I need to take this thyroid medication? How should the nurse respond? a. You will need to take the thyroid medication until the goiter is completely gone. b. Thyroiditis is cured with antibiotics. Then you wont need thyroid medication. c. Youll need thyroid pills for life because your thyroid wont start working again. d. When blood tests indicate normal thyroid function, you can stop the medication.

ANS: C Hashimotos thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy. The client will not be able to stop taking the medication.

A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity and water retention

ANS: C Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The clients family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the clients environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

A nurse plans care for a client with a growth hormone deficiency. Which action should the nurse include in this clients plan of care? a. Avoid intramuscular medications. b. Place the client in protective isolation. c. Use a lift sheet to re-position the client. d. Assist the client to dangle before rising.

ANS: C In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency have thin, fragile bones. Avoiding IM medications, using protective isolation, and assisting the client as he or she moves from sitting to standing will not serve as safety measures when the client is deficient in growth hormone.

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.

ANS: C Nuchal rigidity is a major manifestation of meningitis, a potential postoperative complication associated with this surgery. Meningitis is an infection; usually the client will also have a fever and tachycardia. Range of motion exercises are inappropriate because meningitis is a possibility. Documentation should be done after all assessments are completed and should not be the only action. Although pain medication may be a palliative measure, it is not the most appropriate initial action.

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.

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 Chvosteks sign and Trousseaus 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 client with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance should the nurse assess? a. Potassium b. Sodium c. Calcium d. Magnesium

ANS: C Parafollicular cells produce thyrocalcitonin (calcitonin), which regulates serum calcium levels. Calcitonin has no impact on potassium, sodium, or magnesium balances.

A nurse cares for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. Which actions should the nurse take? (Select all that apply.) a. Administer levothyroxine (Synthroid). b. Administer propranolol (Inderal). c. Monitor the apical pulse. d. Assess for Trousseaus sign. e. Initiate telemetry monitoring.

ANS: C, E The clients laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the clients heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseaus sign is a test for hypocalcemia.

During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall

ANS: D A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a trained dietician to analyze the results. A comprehensive diet history may provide more accurate reflection of nutrient intake, but it is time consuming to acquire and requires a trained/skilled dietary interviewer.

A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients symptoms have now resolved and the client asks, When can I stop taking these medications? How should the nurse respond? a. It is possible for the inflammation to recur if you stop the medication. b. Once you start corticosteroids, you have to be weaned off them. c. You must decrease the dose slowly so your hormones will work again. d. The drug suppresses your immune system, which must be built back up.

B. One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone and adrenal production of cortisol. Decreasing hormone therapy slowly ensures self-production of hormone, not hormone effectiveness. Building the clients immune system and rebound inflammation are not concerns related to stopping high-dose corticosteroids.

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? 1. "Your hair will need to be shaved." 2. "You will receive spinal anesthesia." 3. "You will need to ambulate after surgery." 4. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery."

Rationale: A transsphenoidal hypophysectomy is a surgical approach that uses the nasal sinuses and nose for access to the pituitary gland. Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site.