NUR 433 - Exam 1 (NCLEX QUESTIONS)

You are preparing a care plan for a patient with Cushing disease. Which nursing diagnoses would you be sure to include? (Select all that apply.)

- Risk for Injury related to the potential for bruising - Disturbed Body Image - Risk for injury related to the potential for HTN - Risk for infection

A patient is admitted to the hospital in hypertensive crisis (BP 244/112). Sodium nitroprusside is started to treat BP. Which management strategy, or strategies, would be most appropriate for the patient?

- measuring hourly urine output - continuous BP monitoring with an arterial line - maintenance of a second IV line for fluid administration - assess patient for signs of heart failure and changes in mental status

As the shift begins, you are assigned to care for the following patients. Which patient should you assess first?

58-year-old with hypothyroidism and a heart rate of 48 beats/min

You are providing care for a patient who underwent thyroidectomy 2 days ago. Which laboratory value requires close monitoring by a nurse?

Calcium level

Assessment findings for a patient with Cushing disease include all of the following. For which finding would you notify the physician immediately?

Crackles bilaterally in the lower lobes of the lungs

You admit a patient whose assessment reveals prominent brow ridge, large hands and feet, and large lips and nose. Which pituitary hormone do you suspect is elevated?

Growth hormone

For the patient with pheochromocytoma, which physical assessment technique should you instruct an LPN/LVN to avoid?

Palpating the abdomen in all four quadrants

You are caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires immediate intervention?

Presence of glucose in the nasal drainage

Which change in vital signs would you instruct the UAP to report immediately for a patient with hyperthyroidism?

Rapid heart rate

You are caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would you report to the health care provider immediately?

Temperature elevation to 100.2° F

The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed?

The patient is alert and oriented.

The nurse is caring for a patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed?

The patient makes harsh, vibratory sounds when breathing.

A female patient is admitted with a diagnosis of primary hypofunction of the adrenal glands. Which assessment finding supports this diagnosis?

patchy areas of pigment loss over the face

The patient with hyperparathyroidism who is not a candidate for surgery asks you why she is receiving IV normal saline and IV furosemide. What is your best response?

"Diuretic and hydration therapies are used to reduce your serum calcium."

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate?

"This medicine is given to help your body respond to stress after removal of the adrenal glands."

The LPN/LVN asks you why the patient with Cushing disease has bruising and petechiae across her abdomen. What is your best response?

"Patients with Cushing disease have very fragile capillaries."

A patient with adrenal insufficiency is to be discharged and will take prednisone (Deltasone) 10 mg orally each day. Which instruction would you be sure to teach the patient?

Excessive weight gain or swelling should be reported to the physician.

A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding supports this diagnosis?

Exophthalmos

What are the priority nursing interventions after an abdominal aortic aneurysm repair?

administration of IV fluids and monitoring of kidney function

When providing care for a patient with Addison disease, you should be alert for which laboratory value change?

decreased hematocrit