medsurg 612, 63, 69, 73 evolve questions
The nurse is orienting a new unlicensed assistive personnel (UAP) to the clinic. One of the clients has self-identified as transgender. The UAP states "I don't want to say the wrong thing. What do I call him or her?" What is the nurse's best response?
"Ask how the client would like to be addressed." Asking a client how he or she would like to be addressed shows respect and does not make assumptions. A client's given name and sex as listed on a driver's license may not be how the client chooses to be addressed. Being polite is a given, but may make the client uncomfortable if it is not how he or she prefers to be recognized.
A male-to-female client wishes to discuss breast augmentation surgery. What statement by the client indicates the need for further education by the nurse?
"Fat can be used instead of implants for a more natural look." The options for breast augmentation include saline and silicone; fat injections are not used as a substitute for implants. The use of feminizing hormones for 12 months may yield better results postoperatively but is not mandatory. If hormones are used, once breast tissue enlarges, mammograms should be obtained on a regular basis.
The nurse is educating an 18-year-old girl about the Papanicolaou (Pap) test. Which client statement indicates that further teaching is needed?
"I can have sexual intercourse the night before the test." The client should not have sexual intercourse for at least 24 hours before the test. Annual screening is recommended to 30 years of age with the conventional Pap test. After age 30 and three or more consecutive negative test results, Pap tests may be performed less frequently until 70 years of age. The Pap smear is a cytologic study that is effective in detecting precancerous and cancerous cells in the cervix. The specimen-containing slides from a Pap smear are sent to a laboratory for evaluation.
A client is being discharged with propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse?
"I can return to my job at the nursing home." The client should avoid large crowds and people who are ill because PTU reduces blood cell counts and the immune response, which increases the risk for infection. The client does not, however, need to remain completely at home. Dark urine may indicate liver toxicity or failure, and the client must notify the provider immediately. Taking PTU regularly at the same time each day provides better drug levels and ensures better drug action. The client must notify the provider of weight gain because this may indicate hypothyroidism; a lower drug dose may be required.
A client is scheduled for her final preoperative visit before a vaginoplasty. Which statement by the client indicates a need for further teaching prior to surgery?
"I cannot drink anything at all once I start the bowel preparation." Laxatives are part of the bowel preparation that precede vaginoplasty. This will help decrease the risk of infection. Up until the client goes to bed the night before surgery, the client should increase liquid intake since the bowel preparation can be very dehydrating. Vitamin C can decrease bruising as well as promote wound healing. Antibiotics such as neomycin and metronidazole are given prior to surgery; the client should alert the surgical team about an allergy to metronidazole so a substitution can be made.
A client with possible prostate cancer has a transrectal ultrasound and needle biopsy. The next day, which client statement is of greatest concern to the nurse?
"I feel like I have a fever and my back aches." Low back pain and fever are indications of infection, a potentially life-threatening complication. Worrying about test results, some bright-red spotting, and having no bowel movement since the biopsy are not abnormal for a client who had a transrectal biopsy.
The nurse is providing discharge instructions to a client on spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching?
"I should eat a banana every day." Spironolactone increases potassium levels, so potassium supplements and foods rich in potassium, such as bananas, should be avoided to prevent hyperkalemia. While taking spironolactone, symptoms of hyponatremia such as drowsiness and lethargy must be reported; the client may need increased dietary sodium. Spironolactone will not have an effect on the client's heart rate.
The nurse is completing preoperative teaching for a client who is having a phalloplasty. Which statement by the client indicates further education is necessary?
"I will get my implant during the last surgery." The penile implant will not be placed until several months after all of the surgeries have been completed and the incisions are healed. Skin flaps may be taken from the back, radial forearm, or anterior lateral thigh to create the penis, and fat grafts may be needed to increase its circumference. Phalloplasties are one of the most difficult types of genital surgeries and are usually done in stages.
A client is beginning transdermal estrogen (Climara) therapy. Which statement by the client indicates the need for additional health teaching by the nurse?
"I will need to change out the patch once a month." The transdermal estrogen patch (Climara) is typically dosed as two 0.1-mg patches that are changed twice weekly. If the patch were only changed once a month, the dose would likely be insufficient. Estrogen therapy may cause hypertension, so blood pressure should be regularly monitored, as well as glucose and lipids, since estrogens may elevate triglyceride levels. The risk of venous thromboembolism is markedly increased with the use of estrogens.
The nurse is completing discharge teaching for a client who has been prescribed finasteride (Proscar). What statement by the client indicates that reinforcement is required?
"I will need to have my potassium checked regularly." Although laboratory work will be monitored while taking hormone therapy, this medication does not specifically affect potassium. Dizziness, cold sweats, and chills are associated with finasteride, but these effects tend to decrease over time. If the effects do not diminish, the client should be encouraged to contact the provider. Finasteride is a 5-alpha reductase inhibitor, not an estrogen.
A client with thyroid cancer has just received 131I ablative therapy. Which statement by the client indicates a need for further teaching?
"I'm ready to hold my newborn grandson now." Clients undergoing 131I therapy should avoid close contact with pregnant women, infants, and young children for 1 week after treatment. Clients should remain at least 1 meter (39 inches, or roughly 3 feet) away, and limit exposure to less than 1 hour per day. Some radioactivity will remain in the client's salivary glands for up to 1 week after treatment. Care should be taken to avoid exposing others to the saliva. Flushing the toilet three times after use will ensure that all urine has been diluted and removed. Clothing needs to be washed separately and the washing machine then needs to be run empty for a full cycle before it is used to wash the clothing of others.
The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching?
"If I continue to lose weight, I may need an increased dose." Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy; thyroid replacement therapy should help the client have more energy. The correct time to take thyroid replacement therapy is in the morning. If the client is gaining weight and continues to feel tired, that is an indication that the dose may need to be increased.
A male-to-female client and her partner come to the preoperative appointment. "My partner has some questions. He wants to know about my new vagina. What will it be made of?" What is the nurse's best response?
"It is made with inverted penile tissue." In a vaginoplasty, the neovagina (new vagina) is created from inverted penile tissue or a colon graft. Silicone is used during breast augmentation surgery. Tissue taken from the scrotum and skin grafts may be utilized to create a clitoris or labia.
A client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response?
"The disease can sometimes affect emotional responses." The client may have neurotic or psychotic behavior as a result of high blood cortisol levels. Being honest with the family helps them to understand what is happening. Telling the family not to mind the laughter and that the disease is causing it is vague and minimizes the family's concern. This is the perfect opportunity for the nurse to educate the family about the disease. Cushing's disease is the hypersecretion of cortisol, which is abnormally elevated in this disease and, because the diagnosis has already been made, blood levels do not need to be redrawn. Telling the family that medication is available to help with inappropriate laughing does not assist them in understanding the cause of or the reason for the client's behavior.
Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's response?
"The mood swings should diminish with treatment." Telling the family that the client's mood swings should diminish over time with treatment will provide information to the family, as well as reassurance. Asking how the family feels is important; however, the response should focus on the client. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick; telling them to be patient introduces guilt and does not address the family's concerns.
The nurse has completed discussing the process of gender reassignment surgery with a male-to-female client during her first visit to the office. Which statement by the client indicates a need for more education?
"The surgeon who performed my appendectomy can do my surgery." Not all surgeons are comfortable performing gender reassignment surgeries. Frequently these surgeries are performed by urologists and plastic surgeons. Careful evaluation of the surgeon's expertise should be undertaken. Hormone therapy is required for 12 months prior to surgery, and at least one referral from a qualified psychotherapist is required prior to an orchiectomy. In many cases, insurance will not cover costs associated with gender reassignment surgery.
A client has been prescribed goserelin (Zoladex). The nurse is reviewing discharge teaching with the client. Which statement by the client indicates a need for further teaching?
"This medicine goes deep into my muscle." Goserelin (Zoladex) is a gonadotropin-releasing hormone agonist often used to block the effects of testosterone in male-to-female clients. Goserelin is administered subcutaneously. Tachycardia and dysrhythmias are major side effects of goserelin, and between 1% and 5% of clients sustain a myocardial infarction. Proper administration technique and sharps disposal should be taught before the client is given the first prescription. The nurse should teach the client how to correctly monitor pulse, and the parameters that should be reported to the health care provider.
The nurse is reviewing options and providing education for a client who is experiencing gender dysphoria. What statement by the client indicates that further discussion with the health care team and education is needed?
"To avoid scrutiny at the pharmacy, I'll buy my hormones on the Internet." The use of hormones to feminize or masculinize the body is an option for a client experiencing gender dysphoria; however, their use is prescribed and monitored by health care providers. Frequently endocrinologists are part of the multidisciplinary team. Products purchased via the Internet are from an uncontrolled source and may be hazardous. Individuals experiencing gender dysphoria may live either full- or part-time as the other gender. If the client desires a more permanent change, surgery is an option. Psychotherapy or counseling can provide an outlet to help improve self-image and strengthen coping mechanisms.
The certified nurse-midwife (CNM) completes a cervical biopsy on a client and performs postprocedure teaching. What does the CNM tell the client?
"Use the antiseptic solution rinses to clean your perineum." The client must keep the perineum clean and dry by using antiseptic solution rinses as directed by the health care provider, and should change pads frequently. The client should not have intercourse or lift heavy objects for about 2 weeks after the procedure. The client should rest for 24 hours after the procedure.
A client presents to the clinic to discuss options for treatment for gender dysphoria. He states "I'm confused and I need to talk to somebody, but I don't know what to do and who to talk to. I don't want my parents to know. Can you help me?" What is the nurse's priority response?
"What you say here will be confidential." It is most important to reassure the client that, as long as there is no evidence of abuse or concern of immediate self-harm, discussions with health care providers are confidential. Collaborating with other members of the health care team, including the physician and therapists, is important to provide comprehensive care, but the client must first be reassured of confidentiality; otherwise the client may not be communicative. Insurance coverage is not the top priority in client care.
A 12-year-old girl says to the nurse, "I've had my first period, so can I have a baby now?" How does the nurse respond?
"You are physically able to, but let's discuss becoming a parent." Telling the client that she is able to have a baby and encouraging her to discuss it address the physiologic, psychological, and developmental facts related to the client's question. Telling the client that a boy's sperm must unite with her egg addresses physiologic facts but does not relate to the psychological issues involved with pregnancy and parenthood. Asking the client how she will take care of a baby projects the nurse's own values; it is accusative and could place the girl on the defensive. Simply telling the client that she is able to have a baby is too simple and uninformative.
A middle-aged client is scheduled for her first mammogram. What does the nurse tell the client before the test?
"You should not wear deodorant the day of your mammogram." Deodorant may not be worn before a mammogram because it can show up on the x-ray. Mammography is an x-ray of the soft tissue of the breast. Dietary restrictions are not necessary before a mammogram. The client may experience some temporary discomfort when the breast is compressed during positioning and the test itself.
A client is taking methimazole (Tapazole) for hyperthyroidism and would like to know how soon this medication will begin working. What is the nurse's best response?
"You should see some effects of this medication within 2 weeks." Methimazole is an iodine preparation that decreases blood flow through the thyroid gland. This action reduces the production and release of thyroid hormone. The client should see some effects within 2 weeks; however, it may take several more weeks before metabolism returns to normal. Although onset of action is 30 to 40 minutes after an oral dose, the client will not see effects immediately. Effects will take longer than 1 week to become apparent when methimazole is used. Methimazole needs to be taken every 8 hours for an extended period of time. Levels of triiodothyronine (T3) and thyroxine (T4) will be monitored and dosages adjusted as levels fall.
The nurse is conducting a reproductive assessment of a young adult client. What assessment questions does the nurse ask?
"have you had any sexually transmitted diseases?" "how would you describe yourself?" "if you engage in sexual activities, do you practice safe sex?" "when did you first start menstruating?" Asking the client about a history of sexually transmitted diseases is a question included in the health perception/health management pattern for performing a reproductive assessment. If the answer is "yes," the nurse continues with "When?" and "What type?" Asking the client to describe him- or herself is also included in the self-perception/self-concept pattern. The nurse follows with "Do you feel good or not-so-good about yourself?" It is important to note, if the client is sexually active, that he or she practices (and understands) "safe" sex. This might include the use of condoms, being tested for human immunodeficiency virus, and other measures to keep from acquiring sexually transmitted diseases. The age of onset of menses in women is important to note. Either early or late onset may indicate a problem or the increased likelihood for one to develop. Although the nurse might inquire whether a client has experienced changes in his or her body appearance or function, asking about changes the client might want to see is not important in doing a reproductive assessment.
A client is preparing to be discharged home after her gender reassignment surgery. What are the key points that the nurse will include in her discharge teaching?
"the drain will be removed in about 3-5 days" "you will need to douche routinely to prevent infection" "place the stents or dialators several times a day" The Jackson-Pratt drain will be removed in approximately 3 to 5 days when the drainage is less than 15 to 20 mL/24 hours. Douching routinely with a vinegar and water solution will help prevent infection. Stents or dilators will need to be inserted using a water-based lubricant (not petroleum jelly) several times per day and left in place for 30 to 45 minutes. This will need to continue for several months. Sexual intercourse is also important to keep the vagina dilated. In general, there is no need to refrain from sexual intercourse unless directed by the surgeon.
From what age may a child begin to feel a sense of maleness or femaleness?
2 years By the time a child is around 2 years old, he or she may begin to feel a sense of gender. Children are not born with a sense of gender identity. Some transgender individuals, however, may sense a mismatch from early childhood. This may lead to gender dysphoria or being uncomfortable with one's natal sex.
A newly graduated RN is orienting to a same-day surgery unit. Which client does the charge nurse assign to the new graduate?
A 32-year-old with a breast lump scheduled for a needle biopsy under local anesthesia A needle biopsy of the breast has the least risk for possible complications and the least complex client teaching of the listed procedures. A laparoscopy under general anesthesia, laser excision conization, and transrectal needle biopsy are all procedures that will require complex client teaching and postoperative monitoring.
The human papilloma virus (HPV) test may be collected at the same time as the Papanicolaou (Pap) test for screening. Which finding indicates the highest risk for development of cervical cancer?
Abnormal Pap results and positive HPV test The HPV test can identify many high-risk types of HPV infection associated with the development of cervical cancer and can be done at the same time as the Pap test for women older than 30 years and for women of any age who have had an abnormal Pap test result. Women with an abnormal Pap result and a positive HPV test are at higher risk if not treated. Women who have normal Pap test results and no HPV infection are at very low risk for developing cervical cancer.
A client with syndrome of inappropriate antidiuretic hormone is admitted with a serum sodium level of 105 mEq/L. Which request by the health care provider does the nurse address first?
Administer infusion of 150 mL of 3% NaCl over 3 hours. The client with a sodium level of 105 mEq/L is at high risk for seizures and coma. The priority intervention is to increase the sodium level to a more normal range. Ideally, 3% NaCl should be infused through a central line or with a small needle through a large vein to prevent irritation. Monitoring laboratory values for fluid balance and monitoring urine output are important, but are not the top priority. Monitoring client weight will help in the assessment of fluid balance; however, this is also not the top priority.
A client scheduled for a hysterosalpingogram is interviewed by the nurse. What interview information is critical for the nurse to report to the health care provider before the procedure?
Allergy to shellfish The contrast medium used during hysterosalpingography is iodine-based, so the client will need premedication with an antihistamine and/or corticosteroid before the procedure. Obstetric history, menstrual history, and recent medications are communicated to the provider, but do not require any change in the procedure. Two months between an abortion and this procedure is adequate. This test is done just at the completion of menses so that it would not interrupt a pregnancy, should there be one, in the uterus or the fallopian tube.
Decreased estriol levels in a pregnant client are frequently associated with which condition?
An impending miscarriage Decreased levels of estradiol, total estrogens, and estriol in women indicate possible amenorrhea, climacteric, impending miscarriage, or hypothalamic disorders. Decreased estriol levels in the pregnant client do not indicate impending birth of multiples or infertility.
A client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response?
Ask whether the client has increased cold sensitivity or weight gain. Increased sensitivity to cold and weight gain are symptoms of hypothyroidism, indicating an overcorrection by the medication. The client must be assessed further because he may require a lower dose of medication. A calming environment will not have any effect on the client's heart rate. The client will want to notify the health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client should see the health care provider immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he re-checks his pulse. This time could also be spent providing education about normal ranges for that client.
The nurse reviews the vital signs of a client diagnosed with Graves' disease and sees that the client's temperature is up to 99.6° F. After notifying the health care provider, what does the nurse do next?
Assesses the client's cardiac status completely If the client's temperature has increased by even 1°, the nurse's first action is to notify the provider. Continuous cardiac monitoring should be the next step. Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time. Asking visitors to leave would not be the next action, and if visitors are providing comfort to the client, this would be contraindicated.
A client with iatrogenic Cushing's syndrome is a resident in a long-term care facility. Which nursing action included in the client's care would be best to delegate to unlicensed assistive personnel (UAP)?
Assist with personal hygiene and skin care. Assisting a client with bathing and skin care is included in UAP scope of practice. It is not within their scope of practice to develop a plan of care, although they will play a very important role in following the plan of care. Client teaching requires a broad education and should not be delegated to UAP. Monitoring for signs and symptoms of fluid retention is part of client assessment, which requires a higher level of education and clinical judgment.
A male-to-female client has a body mass index of 29 and is planning to have transvaginal surgery. The nurse is aware that this client is at higher risk for which complications?
Atelectasis Difficulty Ambulating Wound Infection Individuals are considered overweight if they have a body mass index over 24.9. Overweight clients who have had transvaginal surgery are at higher risk for difficulty with ventilation leading to atelectasis, difficulty with ambulating, and wound infection. Nausea/vomiting is a risk after any surgery with general anesthesia. Ileus is a risk with abdominal surgery.
A client with pheochromocytoma is admitted for surgery. What does the nurse do for the admitting assessment?
Avoids palpating the abdomen The abdomen must not be palpated in a client with pheochromocytoma because this action could cause a sudden release of catecholamines and severe hypertension. The tumor on the adrenal gland causes sympathetic hyperactivity, increasing blood pressure and heart rate, not pulmonary edema. A 24-hour urine collection will already have been completed to determine the diagnosis of pheochromocytoma. A client diagnosed with a pheochromocytoma may feel anxious as part of the disease process; providing a roommate for distraction will not reduce the client's anxiety.
Periodic laboratory tests will be monitored for a female-to-male client who is taking testosterone. Which laboratory tests does the nurse tell the client to anticipate will be monitored?
Blood glucose Lipid profile Liver profile Testosterone therapy may cause an increase in blood glucose and liver enzymes as well as a decrease in high-density lipids and an increase in low-density lipids. ABGs will not be affected and will not routinely be monitored. The BUN and creatinine may or may not be monitored as part of routine blood chemistries with testosterone therapy.
A client is beginning testosterone therapy and asks the nurse what effects are to be expected. What physical changes does the nurse tell the client to anticipate?
Breast Atrophy Deepening Voice Menstruation Cessation Testosterone will cause breast and uterine tissue to atrophy. The clitoris will also atrophy. The client's voice will become deeper with testosterone therapy. Menstruation will also cease; however, it is important for the nurse to advise the client that these effects may take up to 1 year to occur. Libido will increase with testosterone therapy. A penis will not develop; this will require surgical intervention if the client desires.
The RN working at the college health clinic is caring for a sexually active 19-year-old female who is having a routine checkup. What information is of greatest concern to the nurse?
Bruising on the vulvar and inner thigh areas Vulvar and inner thigh bruising may indicate that the client is involved in an abusive relationship; this assessment information requires further follow-up by the nurse and health care provider. Irregular periods, disparity in the size of the client's breasts, and the lack of history on rubella status may require further investigation, but are not as high a priority as the possibility that the client may be in danger.
Which routes are used for testosterone administration?
Buccal Intramuscular Oral Transdermal
The nurse is preparing the room for the client returning from a thyroidectomy. Which items are important for the nurse to have available for this client?
Calcium gluconate Emergency tracheostomy kit oxygen suction Calcium gluconate should be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema should occlude the airway. Respiratory distress can result from swelling or damage to the laryngeal nerve leading to spasm, so it is important that the nurse work with respiratory therapy to have oxygen ready at the bedside for the client on admission. Because of the potential for increased secretions, it is important that a working suction device is present at the bedside for admission of the client from the operating room. Furosemide might be useful in the postoperative client to assist with urine output; however, this is not of added importance for this client. Hypertonic saline would not be of benefit to this client as the client is not hyponatremic.
These data are obtained by the RN who is assessing a client who had a transsphenoidal hypophysectomy yesterday. What information has the most immediate implications for the client's care?
Client report of a headache and stiff neck Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. Dry lips and mouth are not unusual after surgery. Frequent oral rinses and the use of dental floss should be encouraged because the client cannot brush the teeth. Any nasal drainage should test negative for glucose; nasal drainage that tests positive for glucose indicates the presence of a cerebrospinal fluid leak. A urine specific gravity of 1.016 is within normal limits.
The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first?
Client who had a parathyroidectomy yesterday and has muscle twitching A client who is 1 day postoperative for parathyroidectomy and has muscle twitching is showing signs of hypocalcemia and is at risk for seizures. Rapid assessment and intervention are needed. Clients with Hashimoto's thyroiditis are usually stable; this client does not need to be assessed first. Although an apical pulse of 51 is considered bradycardia, a low heart rate is a symptom of hypothyroidism. A client with a kidney stone will be uncomfortable and should be asked about pain medication as soon as possible, but this client does not need to be assessed first.
The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit?
Client with Cushing's syndrome who has elevated blood glucose and requires frequent administration of insulin An RN who works with pediatric clients would be familiar with glucose monitoring and insulin administration. A client in Addisonian crisis would best be monitored by an RN from the medical-surgical floor. Although the float RN could complete the admission history, the client with SIADH secondary to lung cancer might require teaching and orientation to the unit that a nurse more familiar with that area would be better able to provide. Discharge teaching specific to adrenalectomy should be provided by the RN who is regularly assigned to the medical-surgical floor and is more familiar with taking care of postoperative adult clients with endocrine disorders.
After receiving change-of-shift report about these four clients, which client does the nurse attend to first?
Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL A glucose level of 36 mg/dL is considered an emergency; this client must be assessed and treated immediately. Although it is important to maintain medications on schedule, the client requiring a dose of desmopressin is not the first client who needs to be seen. A serum potassium of 3.4 mEq/L in the client with hyperaldosteronism may be considered normal (or slightly hypokalemic), based on specific hospital levels. The client reporting a severe headache needs to be evaluated as soon as possible after the client with acute adrenal insufficiency. As an initial measure, the RN could delegate obtaining vital signs to unlicensed assistive personnel.
The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation?
Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN. A client with vocal hoarseness and difficulty swallowing is at higher risk for complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency; this is not a situation to be managed by a newly graduated RN. A client who has just arrived on the unit after a parathyroidectomy requires close observation for bleeding and airway compromise and requires assessment by an experienced nurse.
An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN?
Client with infiltrative ophthalmopathy who needs administration of high-dose prednisone (Deltasone) Medication administration for the client with infiltrative ophthalmopathy is within the scope of practice of the LPN/LVN. Discharge teaching is a complex task that cannot be delegated to the LPN/LVN. A client being admitted for a parathyroidectomy needs preoperative teaching, which must be provided by the RN. A client who has a new diagnosis will have questions about the disease and prescribed medications; teaching is a complex task that is appropriate for the RN.
Which client does the nurse identify as being at highest risk for acute adrenal insufficiency resulting from corticosteroid use?
Client with shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85% for the second time this week Corticosteroids may be used to treat signs and symptoms of asthma, such as shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85%. This places the client at risk for adrenal insufficiency. Corticosteroids are not used to treat signs and symptoms of GI bleeding or peptic ulcer disease (hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena), gallbladder disease (right upper quadrant pain unrelieved for the past 2 days, dark brown urine, and clay-colored stools), or congestive heart failure (edema, shortness of breath, weight gain, and jugular venous distention).
A transwoman presents to her provider's office reporting difficulty sleeping, anxiety, and hypervigilance. She states "I just can't stop thinking about what they did to me last New Year's Eve at work. They slashed my tires. They took my purse. I see it over and over." What is the nurse's best action?
Consult with the health care provider for referral to a counselor. Although accurate documentation is important with regard to the client's statements, this client's symptoms indicate she may be experiencing post-traumatic stress disorder. Male-to-female individuals are more than two times more likely to experience physical violence and discrimination than non-transwomen. Asking the client about drug and alcohol use is an important part of the assessment, but it is only one component, and the use of the word "abusing" implies it is the client who is in the wrong. Assessing for signs of self-harm is also important and part of the physical assessment, but again, it is only one small component.
A client wishes to begin hormone therapy. What criteria must be met for the client to be eligible?
Continued and well-documented gender dysphoria Eval by a qualified mental health professional Signed informed consent To be eligible for hormone therapy, the client must have continued and well-documented gender dysphoria, since hormone therapy is not without risks and does not take effect immediately. The client must also have been evaluated by a qualified mental health professional, and the client must give informed consent. The client must be over the age of 18. If the client has any medical or mental health diagnoses, they must be well controlled; however, simply because a client has a positive medical history, that does not mean the client is ineligible for treatment.
For the 12 months prior to surgery, what is one of the requirements for a client requesting a vaginoplasty or a phalloplasty?
Continuously living in the role of the desired gender identity Vaginoplasty and phalloplasty are very extensive surgeries that alter the external appearance of a client. Continuously living in the gender role that is congruent with the client's gender identity for 12 months is required prior to surgery. It is highly recommended that the client be engaged in regular visits with a mental health professional. There is no requirement for hormone therapy. Vocal therapy may be of benefit to male-to-female clients, but this is not a requirement for surgery.
The nurse is teaching a client about how to monitor therapy effectiveness for syndrome of inappropriate antidiuretic hormone. What does the nurse tell the client to look for?
Daily weight gain of less than 2 pounds The client must monitor daily weights because this assesses the degree of fluid restriction needed. A weight gain of 2 pounds or more daily or a gradual increase over several days is cause for concern. Dry mucous membranes are a sign of dehydration and an indication that therapy is not effective. An increased heart rate indicates increased fluid retention or dehydration and hypovolemia, and either condition is an indication that therapy is not effective. Muscle spasms are associated with hyponatremia and are an indication of a change in the client's neurologic status. Untreated hyponatremia can lead to seizures and coma.
A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. Which medication is used to treat the DI?
Desmopressin (DDAVP) Desmopressin is the drug of choice for treatment of severe DI. It may be administered orally, nasally, or by intramuscular or intravenous routes. Dopamine hydrochloride is a naturally occurring catecholamine and inotropic vasopressor; it would not be used to treat DI. Prednisone would not be used to treat DI. Tolvaptan is a selective competitive arginine vasopressin receptor 2 antagonist and is not used with DI.
A client admitted with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What does the nurse do next?
Encourages the client to rest The client with hyperthyroidism often has wide mood swings, irritability, decreased attention span, and manic behavior. The nurse should accept the client's behavior and provide a calm, quiet, and comfortable environment. Because the client's behavior is expected, there is no need to call the provider. Monitoring the client's cardiac status is part of the nurse's routine assessment. Telling the client to slow down is unsupportive and unrealistic.
A client with diabetes insipidus (DI) has dry lips and mucous membranes and poor skin turgor. Which intervention does the nurse provide first?
Force fluids Dry lips and mucous membranes and poor skin turgor are indications of dehydration, which can occur with DI. This is a serious condition that must be treated rapidly. Encouraging fluids is the initial step, provided the client is able to tolerate oral intake. Lip balm may make the client more comfortable, but does not address the problem of dehydration. A 24-hour urine test will identify loss of electrolytes and adrenal androgen metabolites, but will not correct the dehydration that this client is experiencing. Desmopressin acetate is a synthetic form of antidiuretic hormone that is given to reduce urine production; it improves DI and should not be withheld.
A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L, K+ 5.6 mEq/L, and glucose 72 mg/dL. Which is the first request that the nurse anticipates?
Give 20 to 50 units of insulin with 20 to 50 mg of dextrose in normal saline as an IV infusion to shift potassium into the cells. This client is hyperkalemic. The nurse should anticipate a request to administer 20 to 50 units of insulin with 20 to 50 mg of dextrose in normal saline as an IV infusion to shift potassium into the cells. Spironolactone is a potassium-sparing diuretic that helps the body keep potassium, which the client does not need. Although H2 blocker therapy would be appropriate for this client, it is not the first priority. Arterial blood gases are not used to assess for peaked T waves associated with hyperkalemia; an electrocardiogram needs to be obtained instead.
The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug?
Headache A side effect of fludrocortisone is hypertension. New onset of headache should be reported, and the client's blood pressure should be monitored. Anxiety is not a side effect of fludrocortisone and is not associated with adrenal hypofunction. Nausea is associated with adrenal hypofunction; it is not a side effect of fludrocortisone. Sodium-related fluid retention and weight gain, not loss, are possible with fludrocortisone therapy.
A client had a parathyroidectomy 18 hours ago. Which finding requires immediate attention?
Hoarseness Hoarseness or stridor is an indication of respiratory distress and requires immediate attention. Edema at the surgical site of any surgery is an expected finding. Pain when the client moves the head or attempts to lift the head off the bed is an expected finding after a parathyroidectomy. Any time a client has been intubated for surgery, a sore throat is a common occurrence in the postoperative period. This is especially true for clients who have had surgery involving the neck.
What effect can starting a dose of levothyroxine sodium (Synthroid) too high or increasing a dose too rapidly have on a client?
Hypertension and heart failure Hypertension and heart failure are possible if the levothyroxine sodium dose is started too high or raised too rapidly, because levothyroxine would essentially put the client into a hyperthyroid state. The client would be tachycardic, not bradycardic. The client may have an increased respiratory rate. Shock may develop, but only as a late effect and as the result of "pump failure."
Which laboratory result indicates that fluid restrictions have been effective in treating syndrome of inappropriate antidiuretic hormone (SIADH)?
Increased serum sodium Increased serum sodium due to fluid restriction indicates effective therapy. Hemoconcentration is a result of hypovolemic hyponatremia caused by SIADH and diabetes insipidus. Plasma osmolality is decreased as a result of SIADH. Urine specific gravity is decreased with diabetes insipidus and is increased with SIADH.
A client with hypothyroidism is being discharged. Which environmental change may the client experience in the home?
Increased thermostat setting Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A client with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may be an issue, however. A client with hypothyroidism is not immune-compromised or contagious, so no environmental changes need to be made to the home.
A male-to-female (MtF) client is unable to tolerate estrogen therapy, so she has been prescribed spironolactone (Aldactone). What are the mechanisms of action of this drug when used in this context?
Inhibits androgen binding to androgen receptors Inhibits testosterone secretion Spironolactone inhibits androgen binding to androgen receptors and also inhibits testosterone secretion. It is a diuretic, but is not useful in this context for MtF clients. Ethinyl estradiol blocks follicular maturation and is a combination of estrogen and progestin. 5-Alpha reductase inhibitors such as finasteride (Proscar) block the conversion of testosterone to dihydrotestosterone.
A client diagnosed with hyperpituitarism resulting from a prolactin-secreting tumor has been prescribed bromocriptine mesylate (Parlodel). As a dopamine agonist, what effect does this drug have by stimulating dopamine receptors in the brain?
Inhibits the release of some pituitary hormones Bromocriptine mesylate inhibits the release of both prolactin and growth hormone. It does not decrease the risk for cerebrovascular disease leading to stroke. Increased risk for depression is not associated with the use of bromocriptine mesylate; however, hallucinations have been reported as a side effect. Bromocriptine mesylate does not stimulate the release of any hormones.
A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client?
Instructs the client not to strain during a bowel movement Straining during a bowel movement increases ICP and must be avoided. Laxatives may be given and fluid intake encouraged to help with this. Although deep breathing is encouraged, the client must avoid coughing early after surgery because this increases pressure in the incision area and may lead to a cerebrospinal fluid (CSF) leak. If the client has postnasal drip, he or she must inform the nurse and not blow the nose; postnasal drip may indicate leakage of CSF. The head of the bed must be elevated after surgery.
A client has been diagnosed with hypothyroidism. What medication is usually prescribed to treat this disorder?
Levothyroxine sodium (Synthroid) Levothyroxine is a synthetic form of thyroxine (T4) that is used to treat hypothyroidism. Atenolol is a beta blocker that is used to treat cardiovascular disease. Methimazole and propylthiouracil are used to treat hyperthyroidism.
For feminizing surgery, in what position should the client be placed?
Lithotomy For feminizing surgery, the lithotomy position with feet in stirrups is utilized. The other positions do not allow adequate access and visualization of the area for the multiple components of this procedure.
An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)?
Measure the client's intake and output hourly. Measuring intake and output is a commonly delegated nursing action that is within the UAP scope of practice. Numbness and tingling is part of the client assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures; physical assessment is a complex task that cannot be delegated. An older client receiving an IV at 150 mL/hr is at risk for congestive heart failure; careful monitoring for shortness of breath is the responsibility of the RN.
Which type of thyroid cancer often occurs as part of multiple endocrine neoplasia (MEN) type II?
Medullary Medullary carcinoma commonly occurs as part of MEN type II, which is a familial endocrine disorder. Anaplastic carcinoma is an aggressive tumor that invades surrounding tissue. Follicular carcinoma occurs more frequently in older clients and may metastasize to bone and lung. Papillary carcinoma is the most common type of thyroid cancer. It is slow growing and, if the tumor is confined to the thyroid gland, the outlook for a cure is good with surgical management.
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy?
Monitor oxygen saturation using pulse oximetry. Airway assessment and management is always the first priority with every client. This is especially important for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, although this is not the first priority. Pain control and supporting the head and neck with sandbags are important priorities, but can be addressed after airway assessment.
A client recently admitted with hyperparathyroidism has a very high urine output. Of these actions, what does the nurse do next?
Monitors intake and output Diuretic and hydration therapies are used most often for reducing serum calcium levels in clients with hyperparathyroidism. Usually, a diuretic that increases kidney excretion of calcium is used together with IV saline in large volumes to promote renal calcium excretion. The health care provider does not need to be notified in this situation, given the information available in the question. Cardiac assessment is part of the nurse's routine evaluation of the client. Slowing the rate of IV fluids is contraindicated because the client will become dehydrated due to the use of diuretics to increase kidney excretion of calcium.
A client has returned to the floor after a vaginoplasty. Which assessment finding would concern the nurse?
Numbness in the right leg Clients placed in the lithotomy position for prolonged periods of time are at risk for either compartment syndrome or nerve injury due to pressure on the femoral or peroneal nerve. Edema and pain of the perineum are to be expected, as is drainage in the Jackson-Pratt drain. Drainage should be monitored carefully for amount and color.
A female-to-male client wishes to retain the option of having biological children after transitioning. What available option does the nurse suggest to the client?
Oocyte freezing can occur prior to hormone therapy or gender reassignment surgery. Although expensive, oocyte or embryo freezing should take place prior to the use of any hormone therapy or gender reassignment surgery if the client wishes to preserve reproductive options. Once hormone therapy or gender reassignment surgery has taken place, these options are no longer viable. Oocyte freezing is an option for a client with gender dysphoria.
An older client tells the nurse about vaginal dryness. What does the nurse suggest?
Products such as water-soluble lubricants are helpful with this problem." Information about vaginal estrogen therapy and water-soluble lubricants should be provided to the older woman with vaginal dryness. There is no need to inform the health care provider because vaginal dryness is normal with aging. Additional pelvic examinations are not indicated for this client. Kegel exercises are used for clients with incontinence.
A client presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 84/44 mm Hg, pulse oximetry 98%, and T 98.8° F oral. Which nursing intervention is the highest priority for this client?
Providing isotonic fluids Providing isotonic fluid is the priority intervention because this client's vital signs indicate volume loss that may be caused by nausea and vomiting and may accompany acute adrenal insufficiency. Isotonic fluids will be needed to administer IV medications such as hydrocortisone. Furosemide is a loop diuretic, which this client does not need. Potassium is normally increased in acute adrenal insufficiency, but potassium may have been lost if the client has had diarrhea; laboratory work will have to be obtained. Any restrictions, including sodium, should not be started without obtaining laboratory values to establish the client's baseline.
A client with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant?
Remind the client to avoid drinking coffee and changing position suddenly. Drinking caffeinated beverages and changing position suddenly are not safe for a client with a potential adrenal gland tumor because of the effects of catecholamines. Reminding the client about previous instructions is an appropriate role for a nursing assistant who may observe the client doing potentially risky activities. Client assessment, client teaching, and environment planning are higher-level skills that require the experience and responsibility of the RN, and are not within the scope of practice of the nursing assistant.
The nurse is obtaining a personal health history on a 24-year-old male whose male partner is present. How does the nurse approach questions about his sexual practices?
Respect the client's choice to answer or refuse to answer questions about sexual practices. Respecting the client's choice to answer or not answer questions about sexual practices is an important part of the process of taking the sexual/reproductive history. The nurse must be sensitive about knowing when to ask and when to permit the client his or her privacy. Deferring questions about sexual practices to the health care provider or skipping questions is missing potentially important data; the nurse must establish trust with the client and then proceed with data collection. The nurse is collecting data on the client only, not on the partner or the client's relationship with his partner; directing questions to both of them could be very uncomfortable.
A new transgender client is admitted to the unit for treatment. The nurse uses the wrong pronoun when addressing the client and taking the admitting history. What should the nurse do?
Self-correct and continue with the admitting history. Errors may occur and transgender clients may very well have encountered them before. If there was no intent on the part of the nurse to be disrespectful, the best action is to self-correct and continue with the admitting history. Apologizing repeatedly focuses on the error and emphasizes it. The nurse should not ask for reassignment or fill out a variance as this would imply that something was wrong either with the client's care, the nurse, or the client.
The nurse is teaching a group of young women about the risks for developing cervical cancer. What cancer risk is included in the content of the nurse's presentation?
Starting to have sexual intercourse at a very early age Having intercourse at a very early age and /or multiple sex partners places a woman at high risk for the development of cervical cancer. Eating a diet that is high in fat content, the number of pregnancies, and using a diaphragm have not been identified as increasing the risk for cervical cancer.
A client with pelvic pain is admitted to the same-day surgery unit for a laparoscopic procedure. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?
Taking the client's admission blood pressure and heart rate Although most of the admission assessment and history will be completed by the RN, the admission vital signs can be delegated to UAP. Client teaching is a higher-level skill and should be done by the RN. Catheter insertion is also a higher-level skill and should be done by the RN, unless the UAP has had specialized training to perform this skill safely.
A 68-year-old client has recently undergone a prostate biopsy. Which symptom would indicate immediate referral to the health care provider?
Temperature of 101.6° F (38.7° C) Rarely, sepsis can develop after a prostate biopsy. Clients should contact their health care provider immediately if they experience fever, pain when urinating, or penile discharge. Expected findings may include slight soreness, light rectal bleeding, and blood in the urine or stools for a few days. Semen may be red or rust-colored for several weeks.
A client is referred to a home health agency after a transsphenoidal hypophysectomy. Which action does the RN case manager delegate to the home health aide who will see the client daily?
Test any nasal drainage for the presence of glucose. Cerebrospinal fluid (CSF) will test positive using a glucose "dipstick." Nasal drainage that is positive for glucose after a transsphenoidal hypophysectomy would indicate a CSF leak that would require immediate notification of the health care provider. Home health aides can be taught the correct technique to perform this procedure. Assessing for symptoms of infection and documenting them in the record, medication administration, and setting up medication are not within the scope of practice of the home health aide.
The prostate-specific antigen (PSA) test is used in screening for prostate cancer. Which statement is true regarding this test?
The PSA test can be used to monitor the disease after prostate cancer treatment. The PSA test is used to screen for prostate cancer and to monitor the disease after cancer treatment. PSA levels less than 2.5 ng/mL may be considered normal, although there is no agreement on that value and how it is affected by age. Elevated PSA levels may be associated with prostate cancer. Older men, particularly African-American men, often have a higher normal PSA, especially as they age.
What is the correct way to refer to a client who self-identifies as the opposite gender?
Transgender Transgender describes clients who self-identify as the opposite gender or whose gender does not match the one with which they were born (or natal sex). It is never correct to refer to someone as "a transgender," or to say someone is "transgendered." Transvestite may have negative connotations in some cultures. The best way to determine how someone wishes to be addressed is always to ask the client.
A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention?
Unlicensed assistive personnel pulling the client up in bed by the shoulders The client with hyperparathyroidism is at risk for pathologic fracture. All members of the health care team must move the client carefully. A lift sheet should be used to re-position the client. The client with hyperparathyroidism is not restricted from eating and should maintain a balanced diet. The client can benefit from moderate exercise and physical therapy, and is not restricted from having visitors.
A client has recently had a vaginoplasty and has noticed stool coming from her vagina. She calls her provider's office and the nurse advises her to immediately go the emergency department. What is the nurse's concern?
Vaginal-rectal fistula A vaginal-rectal fistula is caused by a rectal perforation during the surgery to create the vagina and may lead to passage of stool into the vagina. This is a major complication that will necessitate a temporary colostomy as well as extensive wound care. A urinary catheter is usually left in during the immediate postoperative period. A labial hematoma would be apparent on the labia but would not cause passage of stool. A prolapse or herniation of contents would not create passage of stool.
The nurse is caring for a client with hypercortisolism. The nurse begins to feel the onset of a cold but still has 4 hours left in the shift. What does the nurse do?
Wears a facemask when caring for the client A client with hypercortisolism will be immune-suppressed. Anyone with a suspected upper respiratory infection who must enter the client's room must wear a mask to prevent the spread of infection. Although asking another nurse to care for the client might be an option in some facilities, it is not generally realistic or practical. The nurse, not the client, feels the onset of the cold, so monitoring the client for cold-like symptoms is part of good client care for a client with hypercortisolism. Refusing to care for the client after starting care would be considered abandonment.
A client with Cushing's disease says that she has lost 1 pound. What does the nurse do next?
Weighs the client Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease. Weighing the client with Cushing's disease is part of the nurse's assessment. Crackles in the lungs indicate possible fluid retention, which would cause weight gain, not weight loss. Urine specific gravity will help assess hydration status, but this would not be the next step in the client's assessment. Forcing fluids is not appropriate because usually excess water and sodium reabsorption cause fluid retention in the client with Cushing's disease.
How does the drug desmopressin (DDAVP) decrease urine output in a client with diabetes insipidus (DI)?
Works as an antidiuretic hormone (ADH) in the kidneys Desmopressin is a synthetic form of ADH that binds to kidney receptors and enhances reabsorption of water, thus reducing urine output. Desmopressin does not have any effect on sodium reabsorption. It may cause a slight increase or a transient decrease in blood pressure, but this does not affect urine output. Desmopressin does not increase cardiac output.
A male-to-female client is beginning estrogen therapy. Which data obtained from the client's history are of particular concern to the nurse?
body mass index of 32 one pack per-day smoker take multiple meds for BP control
A client wants to know what complications may occur after a phalloplasty. About which complications does the nurse inform the client?
dissatisfaction with results donor graft site scarring penile necrosis urinary tract stenosis Phalloplasty is one of the most difficult reconstructive genital surgeries to perform, and many female-to-male (FtM) clients do not choose to have phalloplasty surgery due to its low success/satisfaction rate. Donor graft scarring and urinary tract stenosis are possible. Although not a common occurrence, necrosis of the neopenis may occur. FtM clients do not have a prostate gland.
The nurse is facilitating a discussion at an LGBTQ gathering at the local community college. One student asks what kind of genital surgeries are available for someone who wants to transition from female to male (FtM). What options will the nurse tell the group are available for FtM clients?
vaginectomy metoidioplasty scrotoplasty The types of genital surgeries the FtM client may undergo include vaginectomy (removal of the vagina), metoidioplasty (creation of a small penis using hormone-enhanced clitoral tissue), and scrotoplasty (creation of a scrotum). Penectomy is surgical removal of the penis, which is not a genital surgery associated with FtM sexual reassignment. A mastectomy is the removal of breast tissue and, although many clients opt for this surgery, it is not a genital surgery.