NCLEX questions - Evolve
Which physiologic changes of the musculoskeletal system are related to aging? Select all that apply. a. Slowed movement b. Cartilage degeneration c. Increased bone density d. Increased range of motion e. Increased bone prominence
A,B,E The physiologic changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.
The blood reports of a client suggest hyperfunctioning of the adrenal glands. Which finding supports the diagnosis? Serum sodium of 130 mEq/L (130 mmol/L) Serum bicarbonate of 24 mEq/L (24 mmol/L) Blood urea nitrogen of 12 mg/dL (4.29 mmol/L) Serum potassium of 2.8 mEq/L (2.8 mmol/L)
The hyperfunctioning of the adrenal gland is manifested as decreased serum potassium levels. Normal levels of serum potassium lie between 3.5 and 5 mEq/L (3.5-5 mmol/L). Therefore, a serum potassium concentration of 2.8 mEq/L (2.8 mmol/L) is abnormal and supports the diagnosis. The normal serum sodium concentration ranges from 135 to 145 mEq/L (135-145mmol/L); while 130 mEq/L (135 mmol/L) is low, hypernatremia occurs in hyperfunctioning of the adrenal glands. The normal serum bicarbonate concentration ranges from 22 to 26 mEq/L (22-26mmol/L). The normal levels of blood urea nitrogen range from 7 to 20 mg/dL (2.5-7.14 mmol/L).
While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? Select all that apply. a. "I have difficulty judging things." b. "I forget to take medicines." c. "I am unable to do financial calculations." d. "I get confused about the proper date and time." e. "I am unable to recall words during conversations with my family."
a, c, e Poor judgment, loss of the ability to calculate, and loss of language skills are related to cognitive impairment. These changes may develop due to an imbalance of neurotransmitters in brain. Forgetfulness and getting confused are symptoms that may be associated with normal aging changes.
Which statement about psychotherapeutic drugs in elderly clients requires correction? a. Tricyclic antidepressants may increase anxiety in elderly clients. b. Normal dosage of lithium may result in lithium toxicity in elderly clients. c. Elderly clients on antipsychotic drugs are susceptible to orthostatic hypotension. d. Low serum levels of the drug are reported in elderly clients on psychotherapeutic drugs.
d. High serum levels are recorded in elderly clients on psychotherapeutic drugs. Instead of decreasing the anxiety, tricyclic antidepressant drugs may increase the anxiety in older adults. Normal dosage of lithium may result in lithium toxicity in elderly clients, thus necessitating the need to administer low doses of the drug. Orthostatic hypotension, anticholinergic adverse effects, sedation, and extrapyramidal symptoms are more common in elderly clients taking psychotherapeutic drugs.
Increasing consumption of which food selection is most important for the nurse to teach post-menopausal clients? Fish Fruit Yogurt Legumes
Yogurt Female clients usually attain menopause at 55 years of age. Due to reduced amounts of circulating estrogen in postmenopausal women, bone density decreases, thus increasing the risk of osteoporosis. Older female clients should be advised to consume foods rich in calcium such as yogurt, which helps reduce loss of bone mass. Fish is a good source of protein and omega-3-fatty acids. Fruits are rich in fiber, which prevents constipation and reduces serum cholesterol. Legumes are a good source of protein. However, these dietary suggestions for older female clients are less beneficial when compared to the consumption of yogurt.
After reviewing the reports of a client, the nurse suspects hypofunctioning of the adrenal gland. Which findings are consistent with hypofunctioning of the adrenal gland? Select all that apply. 1. Increased serum calcium 2. Decreased serum cortisol 3. Decreased serum sodium 4. Decreased serum potassium 5. Increased serum glucose
1,2,3 Hypofunctioning of the adrenal gland is manifested by increased serum calcium, decreased serum cortisol, and decreased serum sodium levels. Decreased serum potassium and decreased serum bicarbonate levels are associated with hyperfunctioning of the adrenal gland. Normal to increased serum glucose is associated with hyperfunctioning of the adrenal gland.
The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client? Assess breath sounds and respiratory effort. Establish airway by positioning, suctioning, and oxygen as needed Maintain vascular access using a large-bore catheter. Use direct pressure for external bleeding. Prepare for chest decompression if needed.
1.Establish airway by positioning, suctioning, and oxygen as needed 2.Assess breath sounds and respiratory effort. 3.Prepare for chest decompression if needed. 4. Maintain vascular access using a large-bore catheter. 5.Use direct pressure for external bleeding.
A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation? Using a jaw-thrust maneuver to establish an airway Providing bag-valve-mask (BVM) ventilation Palpating for the presence of a radial pulse Removing the clothing with scissors Monitoring systolic blood pressure Assessing the score of eye opening
A client with trauma should be assessed for airway, breathing, circulation, disability, and exposure. A jaw-thrust maneuver helps to establish an airway and breathing, and bag-valve-mask (BVM) ventilation with 100 percent oxygen source ensures ventilatory assistance. Following respiratory assessment is the circulation assessment. The pulse of the client is palpated at the radial, femoral, and carotid areas, and the systolic blood pressure is monitored. Disability is assessed using the Glasgow Coma Scale to find out the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.
The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? Thinning subcutaneous layer Degeneration of elastic fibers Decreased dermal blood flow Benign proliferation of capillaries
Decreased dermal blood flow With decreased dermal blood flow the client is susceptible to dry skin; the nurse should advise the client to apply moisturizer when the skin is moist. If a client is found to have a thinning subcutaneous layer, the nurse should teach the client to dress warmly in cold weather. If a client presents with degenerated elastic fibers, the nurse should check the skin turgor on the forehead or chest of the client. If a client has benign proliferation of the capillaries, this indicates cherry hemangiomas; the nurse should teach the client that these are benign.
A nursing student lists the preventive and primary care services available in schools, primary healthcare provider's offices, occupational health clinics, community health centers, and nursing centers. Which service provided by these centers is most expensive? Running errands Health education Disease management Routine physical examinations
Disease Management Disease management is the most expensive service provided by community health centers. Running errands is inexpensive, and if the person walks or rides a bike, can be used as a health promotion activity. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.
The nurse is caring for a client in labor whose medical report states posterior pituitary hormone deficiency. Which medication administration is required for the client considering the medical condition? Oxytocin to promote uterine contractions Prolactin to promote breast milk ejection Luteinizing hormone to promote painless labor Follicle-stimulating hormone to promote estrogen secretion
Oxytocin to promote uterine contractions Oxytocin is a posterior pituitary hormone that acts on the uterus to stimulate uterine contractions. Therefore the nurse should administer oxytocin to the client. Prolactin is an anterior pituitary hormone that promotes breast milk production, not milk ejection. Luteinizing hormone is an anterior pituitary hormone that stimulates progesterone secretion and ovulation and does not promote painless labor. Follicle-stimulating hormone is secreted by the anterior pituitary and is involved in estrogen secretion and follicle maturation.
A client who is prescribed diuretic therapy develops metabolic alkalosis. To which intervention should the nurse give priority as the healthcare team corrects the alkalosis? Preventing falls Monitoring electrolytes Administering antiemetics Adjusting the diuretic therapy
Preventing falls is the priority nursing intervention as the healthcare team corrects the alkalosis. A client with alkalosis has hypotension and muscle weakness, which increases the risk for injury due to falls. Monitoring electrolytes and adjusting diuretic therapy require prescriptive authority and are important actions primarily managed by the healthcare provider. Antiemetics are prescribed by the healthcare provider when there is nausea and vomiting. Although nurses have an important role in assisting the healthcare team with implementing prescriptions, preventing falls is the priority action within the nursing scope of practice and does not require a prescription.
The nurse is conducting a brief neurologic examination to test the level of consciousness in a client who sustained injuries in a bus accident. Which order should the nurse follow to assess the client's condition? Assess if the client has proper shape, size, equality, and reactivity in pupil. Assess if the client is responsive to voice. Assess if the client is unresponsive. Assess if the client is responsive to pain. Asses if the client is alert.
The level of consciousness is a measure of the degree of disability. To assess the level of consciousness, determine the client's condition by using the mnemonic AVPU. Assess if the client is alert, whether responsive to Voice, followed by his/her response to Pain, whether Unresponsive to pain, and finally assess the size, equality, and reactivity in the pupil to determine the disability of the client's condition.
What are the clinical manifestations of actinic keratosis in a client? Select all that apply. a. Firm, nodular lesions b. Small papules with dry skin c. Wrinkled, weather-beaten skin d. Pearly papules with a central crater e. Irregularly shaped, pigmented papule
b, c Small papules with dry skin and wrinkled, weather-beaten skin are clinical manifestations of actinic keratosis. Firm, nodular lesions are clinical manifestations of squamous cell carcinoma. Pearly papules with a central crater are the clinical manifestations of basal cell carcinoma. Irregularly shaped, pigmented papules are the clinical manifestations of melanoma.
Which hormone overproduction is associated with carpel tunnel syndrome in clients? Growth hormone Antidiuretic hormone Parathyroid hormone Aldosterone hormone
Growth Hormone Overproduction of growth hormone is associated with carpel tunnel syndrome. Overproduction of aldosterone hormone is associated with Conn's syndrome. Antidiuretic hormone overproduction can result in syndrome of inappropriate antidiuretic hormone. Overproduction of parathyroid hormone results in hyperparathyroidism.
The nurse is teaching a client about automatic epinephrine injectors. Which statement made by the client indicates a need for additional education? "I will keep the device in the refrigerator." "I will keep the device away from light." "If the cap is loose, I will obtain a replacement device." "I will have at least two drug-filled devices on hand at all times."
The device should be protected from extreme temperatures. Therefore the device should not be refrigerated. The device should be protected from light. If the cap is loose or comes off accidentally, the client should obtain a replacement device. The client should have at least two drug-filled devices on hand in case more than one dose is required.
The nurse is assessing a client with an open fracture who is in a trauma condition. What are the nursing interventions in order of priority? 1.Assessing for airway patency, breathing, and circulation 2.Administering morphine sulfate intravenously 3.Applying direct pressure on the injured area 4.Cutting away the clothing from the fracture site
The priority nursing intervention for a client in a trauma condition is to assess for airway patency, breathing, and circulation. Next priority is to cut away clothing from the fractured site. After clothing is removed, direct pressure is applied on the injured area to prevent bleeding. After stabilizing the client, pain is managed by administering morphine sulfate through the intravenous route.
Which drug acts as an abortifacient in female clients? Mifepristone Metyrapone Cyproheptadine Aminoglutethimide
Mifepristone is an antiprogesterone that blocks the progesterone receptors and acts as an abortifacient. Metyrapone, cyproheptadine, and aminoglutethimide are used to treat hyperfunctioning of the adrenal glands (Cushing's disease/syndrome).
Which instruction would be most beneficial for an aging African-American client with hypertension? "Check the pulse daily." "Have an annual urinalysis." "Record blood pressure weekly." "Visit an ophthalmologist monthly."
"Have an annual urinalysis." African-American clients have 20% less blood flow to the kidneys because of high sodium consumption. This causes anatomical changes in the blood vessels, thereby increasing the risk of kidney failure. Therefore instructing the client with hypertension to have an annual urine examination would be beneficial. If the client has protein in the urine, this is a sign of high blood pressure and can signify kidney damage. Checking the pulse daily poses no harm to the individual, but does not determine if the client has hypertension. Recording the blood pressure weekly is not a good indicator of an aging African-American client with hypertension. The client's blood pressure should be taken at least daily to determine if the client has problems. If the client has an eye-related problem, visiting an ophthalmologist should be suggested.
The nurse is caring for a hospitalized immunosuppressed client. Which interventions will be beneficial for safe and effective care of this client? Select all that apply. 1. Advise the client to eat raw fruits daily 2. Avoid using supplies from common areas 3. Encourage activity at an appropriate level 4. Use alcohol-based hand rubs before touching the client 5. Change gauze-containing wound dressing on alternative days
2, 3, 4 Supplies from common areas should not be used for neutropenic clients to prevent contracting infection. Physical activity at a level appropriate for client's condition should be encouraged to promote health. Alcohol-based hand rubs should be used before touching the client to decrease the risk of infection. Immunosuppressed clients should avoid eating raw fruits and vegetables; they should eat low-bacteria diet. Gauge-containing wound dressings should be changed on a daily basis, not on alternative days, to prevent infection.
Which hormonal deficiency reduces the growth of axillae and pubic hair in female clients? Growth hormone Antidiuretic hormone Thyroid-stimulating hormone Adrenocorticotropic hormone
An adrenocorticotropic hormone deficiency causes a reduced growth of axial and pubic hair in women. A growth hormone deficiency causes decreased muscle strength and decreased bone density. An antidiuretic hormone deficiency causes excessive urine output and a low urine specific gravity. A thyroid-stimulating hormone deficiency results in hirsutism and menstrual abnormalities.
The nurse is reviewing the blood test reports of a child whose blood sample was tested after receiving a general anesthetic. The nurse finds that the client has increased intracellular calcium levels. What medication would be beneficial to the client? Aspirin (Anacin) Naproxen (Aleve) Ibuprofen (Advil) Dantrolene (Dantrium)
Dantrolene The administration of general anesthetic sometimes causes malignant hyperthermia in clients. Malignant hyperthermia is characterized by increased levels of intracellular calcium in the body. Dantrolene sodium (Dantrium) reduces the muscle tone and metabolism and thereby decreases the calcium levels in the body. Therefore dantrolene is used to antagonize the effects of malignant hyperthermia in this client. Aspirin (Anacin) should not be given to children because it increases the risk of Reye syndrome. Drugs such as naproxen (Aleve) and ibuprofen (Advil) may not reduce calcium levels in the body and thus may not be used to reverse the effects of malignant hyperthermia in the client.
Which parameter monitoring should be the nurse's priority while caring for a patient with hypothyroidism? Pulse rate Blood pressure Resp rate Body temp
Resp Rate Hypothyroidism is associated with a decreased respiratory rate. Therefore monitoring the client's respiratory rate should be the nurse's top priority. While hypotension, hypothermia, and pulse rate are important, they are not the priority.
A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? Oral hydroxyurea Vit B12 injections Oral Iron supplements Erythropoietin injections
Vitamin B12 injections A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200- 835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia due to a vitamin B12 deficiency and should be given vitamin B12 injections. Vitamin B12 cannot be given orally to a client with pernicious anemia because the client does not produce the intrinsic factors needed to absorb Vitamin B12. Hydroxyurea is administered orally to clients with hemochromatosis. Oral iron supplements are given to clients with iron deficiency anemia. Erythropoietin injections are given to clients who have low red blood cells, hemoglobin, and hematocrit.
Which gerontologic assessment findings of the auditory system are related to the inner ear? Select all that apply. a. Hair cell degeneration b. Reduced blood supply to the cochlea c. Atrophic changes of the tympanic membrane d. Decline in the ability to filter out unwanted sounds e. Less effective vestibular apparatus in the semicircular canals
a,b,e Hair cell degeneration, reduced blood supply to the cochlea, and less effective vestibular apparatus in the semicircular canals are assessment findings related to the inner ear. Atrophic changes of the tympanic membrane is an assessment finding associated with the middle ear. A decline in an ability to filter out unwanted sounds is an assessment finding related to the brain.
A nurse instructs a 70-year-old client to dress warmly in cold weather. Which physical changes seen in the client necessitate this instruction? Select all that apply. a. Reduced sebum production b. Degeneration of elastic fibers c. Decreased dermal blood flow d. Thinning of the subcutaneous layer e. Decreased vasomotor responsiveness
d, e Thinning of the subcutaneous layer and decreased vasomotor responsiveness will increase the risk of hypothermia. To prevent hypothermia, the nurse instructs the client to wear warm clothing. Reduced sebum production can increase the size of pores, producing comedones. Degeneration of elastin will decrease the skin turgor of the client but does not produce hypothermia. Decreased dermal blood flow will cause risk of dry skin, which does not require the intervention of warm clothing.
A nursing student counsels a 70-year-old female client about changes in the reproductive system caused by aging. Which statement made by the client indicates effective learning? "I should reduce my intake of dietary calcium." "I should limit my Kegel exercises." "I should undergo regular clinical breast examinations." "I should report to my primary healthcare practitioner if my nipples do not become erect."
"I should undergo regular clinical breast examinations. A 70-year-old female client may need regular clinical breast examinations to detect masses or other changes that may indicate the presence of cancer. The client should take an adequate amount of calcium to prevent osteoporosis. Performing Kegel exercises strengthens pelvic muscles and reduces urinary incontinence. The erection of the nipples decreases as age increases; this finding does not need to be reported to the primary healthcare provider.
While assessing the vital signs of an elderly alcoholic client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. What other findings does the nurse expect to observe? Select all that apply. 1. Body temperature of 84.2 °F 2. Body temperature of 100.6 °F 3. Blood pressure of 100/62 mmHg 4. Respiratory rate of 12 breaths/minute 5. Respiratory rate of 16 breaths/minute
1, 3, 4 Alcohol acts as a vasodilator in the body; therefore, it causes dilation of surface blood vessels and results in hypothermia due to loss of body heat. However, the skin of the alcoholic client gives a false sensation of warmth, even while the client shows symptoms of hypothermia. Therefore the nurse finds the body temperature of the client is less than 86 °F. Cardiovascular collapse can result in clients with severe hypothermia. During severe hypothermic conditions, the blood pressure of the client decreases. Hypothermia lowers the respiratory rate; therefore, the client may have a respiratory rate of 12 breaths/minute. As the client does not have hyperthermia, he or she does not have a body temperature of 100.6 °F. The normal respiratory rate for elderly clients is in the range of 12 to 18 breaths per minute. Individuals with hypothermia may not have a normal respiratory rate of 16 breaths/minute.
The nurse observes that a client with sickle cell anemia and on a blood transfusion regimen has cardiac dysrhythmias due to iron overdose toxicity. Which medication is most beneficial to this client? Deferasirox Deferiprone Deferoxamine Ferrous gluconate
Deferoxamine A client with sickle cell anemia requires frequent blood transfusions and is at an increased risk for iron toxicity. Deferoxamine is an intravenous medication that chelates with the iron and reduces iron overload or hemochromatosis in the client in less time. Therefore it is the most beneficial drug in this situation. Deferasirox and deferiprone are oral chelating agents and, therefore, show delayed action compared to deferoxamine. Iron supplements such as ferrous gluconate should not be administered to the client as they further increase the risk of iron overload.
The client's pituitary gland must be removed. Which surgery will the client undergo? Mastectomy Prostatectomy Thyroidectomy Hypophysectomy
Hypophysectomy A hypophysectomy is the surgical removal of the pituitary gland or its tumor. A mastectomy is the surgical removal of breast tissue. A prostatectomy is the surgical removal of the prostate gland. A thyroidectomy is the surgical removal of the thyroid gland.
An 80-year-old client with depression requires the prescription of antidepressant drugs. Which tricyclic antidepressant drug is appropriate? Doxepin Amoxapine Nortriptyline Trimipramine
Nortriptyline and desipramine are preferred for use in the elderly as these antidepressant drugs have less anticholinergic activity. Doxepin, amoxapine, and trimipramine have more cholinergic activity than nortriptyline and are not the preferred drugs for elderly clients.
Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? Calcium of 9.5 mg/dL (2.375 mmol/L) Potassium of 7.02 mEq/L (7.02 mmol/L) Bicarbonate of 22.8 mEq/L (22.8 mmol/L) Phosphorus of 4.1 mg/dL (1.3243 mmol/L)
The normal level of serum potassium is between 3.5-5.0 mEq/L (3.5 and 5.0 mmol/L). Elevated potassium levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal levels of serum phosphorus are between 2.4-4.4 mg/dL (0.78 and 1.42 mmol/L). The normal levels of serum calcium are usually between 8.6-10.2 mg/dL (2.15 and 2.55 mmol/L). The normal level of serum bicarbonate is between 22 and 26 mEq/L or mmol/L. These findings are not associated with the risk of developing muscle weakness and cardiac arrhythmias.
The registered nurse is teaching a community event about health promotion activities appropriate for good skin health. Which instructions given by the nurse would be beneficial? Select all that apply. 1. "Eat foods rich in vitamin B." 2. "Sleep for longer periods of time." 3. "Use alkaline soaps for better hygiene." 4. "Use sunscreen of sun protection factor (SPF) 30 daily." 5. "Avoid exposure to sun after administering ketoconazole."
1,2,5 Deficiency of vitamin B4 (niacin) and B6 (pyridoxine) are manifested as erythema, bullae, and seborrhea-like lesions. Deficiency of biotin, a B-complex vitamin, may cause rashes and alopecia. Adequate rest increases tolerance to itching, thereby decreasing skin damage from scratching in pruritic skin diseases. Some medications potentiate the effect of the sun causing sunburns. Acidic activity of the skin protects against bacterial overgrowth. Alkaline soaps neutralize the skin thereby decreasing the protection. Sunscreen of SPF 15 should be used daily by everybody. People with history of skin cancer or problems with photosensitivity may use sunscreen with SPF of at least 30.
While reviewing the laboratory results of a client in an acute care setting, the nurse finds urine output of 250 mL in 24 hours, blood osmolality of 310 milliosmoles per kg, and a systolic blood pressure of 90 mm Hg. What is the priority nursing intervention in this situation? Consider it as a normal finding. Advise the client to drink 2 to 3 L of water daily. Assess the creatinine and blood urea nitrogen (BUN) levels. Request an increase in the intravenous fluid rate from the healthcare provider.
Request an increase in the intravenous fluid rate from the healthcare provider. Normal urine output is in the range of 600 to 2500 mL per 24 hour and normal blood osmolality is in the range of 275 to 295 milliosmoles per kilogram. The normal systolic pressure is 120 mm Hg. The client's medical record indicates an abnormal urine output of 250 mL in the past 24 hours, blood osmolality of 310 milliosmoles per kg, and systolic blood pressure of 90 mm Hg, which indicate severe volume depletion. Therefore the priority nursing intervention is requesting an increase in the intravenous fluid rate from the healthcare provider to prevent permanent kidney damage. A healthy individual is advised to drink 2 to 3 L of water daily. The client's creatinine and blood urea nitrogen (BUN) level are assessed to detect kidney function, but only after the client is made stable.
Which parental occupations would require the nurse to closely monitor a toddler-age client for lead toxicity? Select all that apply. a. Ceramics work b. Radiator repair c. Healthcare work d. Bridge repair work e. Brass foundry work
a, b, c, d Parental occupations that may place a toddler-age client at risk for lead toxicity include ceramics work, radiator repair, bridge repair work, and brass foundary work. Healthcare work does not lead to an increased risk for lead toxicity.
The nurse assesses a 65-year-old client's electronic medical records and notices a history of increased lens density. Which nursing actions will be most appropriate for this client? Select all that apply. a. Performing keratoplasty b. Performing phacoemulsification c. Monitoring for pain and eye redness d. Monitoring the client's blood glucose levels e. Assessing if the client is under antiplatelet medication
d, e A client with cataracts has increased lens density due to drying and compression of older lens fibers. Clients with disease conditions such as diabetes mellitus may develop cataracts. Therefore the client's blood glucose levels should be assessed to determine the severity of the disease. Surgery is the only "cure" for cataracts. Before performing surgery, the client should be assessed for any conditions that may affect blood clotting, such as use of aspirin and clopidogrel. Phacoemulsification is the surgical procedure performed in a client with cataracts in which the lens is extracted. Keratoplasty is performed in a client with improper corneal shape. Pain and redness is not observed in age-related cataract. Both phacoemulsification and keratoplasty are surgical procedures and not nursing actions.
Which clinical manifestations in a client indicate hyperfunctional thyroid gland? Select all that apply. 1. Anemia 2. Diarrhea 3. Weight loss 4. Decreased appetite 5. Distant heart sounds
2,3 Diarrhea and weight loss are the characteristic manifestations of a hyperfunctional thyroid gland. Anemia is seen in a client with a hypofunctional thyroid and decreased levels of thyroid hormone. Decreased appetite and distant heart sounds are symptoms of a hypofunctional thyroid gland.
The nurse instructs the son of an older client about age-related immune system changes and associated care measures. Which statement made by the son during a follow-up visit indicates a need for further instruction? "My parent has a private room at home." "My parent has received the pneumococcal vaccination recently." "My parent comes in for check-ups only whenever he or she has a fever." "My parent has been given a second dose of the pertussis vaccination."
"My parent comes in for check-ups only whenever he or she has a fever." Older clients should have regular check-ups even in the absence of fever. Because aging causes reduced neutrophil function, some infections may not show fever symptoms. Older adults should have a private room at home to avoid other adults who may have viral infections. Because older adults have a decreased production of antibodies against new antigens, the caretaker should ensure that the older client has received updated vaccinations against infectious diseases such as pneumococcus and pertussis.
The physical examination of a client reveals moon face, buffalo hump, and truncal obesity. The laboratory report reveals salivary cortisol level of 3.0 ng/mL (9.54 nmol/L). Which other manifestations would be present in the client? Select all that apply. 1. Edema 2. Osteoporosis 3. Hypogonadism 4. Muscle atrophy 5. Barrel-shaped chest
1, 2, 4 Hypercortisolism may result in sodium and water reabsorption and retention, leading to hypervolemia and edema. Hypercortisolism may also cause mineral loss, which leads to osteoporosis. This condition may also cause musculoskeletal changes caused by nitrogen depletion and mineral loss. This may lead to muscle atrophy. Moon face, buffalo hump, and truncal obesity are clinical manifestations of hypercortisolism. A normal salivary cortisol is 2.0 ng/mL (6.36 nmol/L); a higher level also indicates hypercortisolism. Hypogonadism is a loss of secondary sexual characteristics, which may occur due to increased prolactin secretion. A barrel-shaped chest is seen in clients with acromegaly (due to increased growth hormone secretion) and chronic obstructive pulmonary disease.
Which treatment intervention should be provided to a client diagnosed with Cushing's disease? Increase cortisol levels Increase sodium levels Decrease blood glucose levels Decrease serum calcium levels
Decreased BG levels Cushing's disease affects the glucose metabolism and results in reduced glucose uptake by tissues and increased blood glucose levels; therefore interventions to regulate blood glucose levels should be undertaken. Hypersecretion of cortisol causes Cushing's disease; therefore interventions should be aimed at decreasing the cortisol levels. Sodium levels are elevated in hypercortisolism; therefore interventions to decrease these levels should be initiated. Measures to increase the low serum calcium levels in Cushing's disease will be beneficial to the client.
