Test 3 NCLEX Study: Hormonal Regulation & Oxygenation
Which of the following medications affect thyroid hormone levels? A. PTU B. Inderal C. Lasix D. Vasopressin
A. PTU
A registered nurse teaches a nursing student about safety measures to be followed when using oxygen. Which statement if made by the nursing student indicates a need for further teaching? 1. "I should store oxygen cylinders by placing them upright." 2. "I should check the oxygen level of portable tanks before transporting." 3. "I should keep the oxygen-delivery system 5 ft away from any open flames." 4. "I should place an 'Oxygen In Use' sign on the patient's door and in the room."
3. "I should keep the oxygen-delivery system 5 ft away from any open flames." The nurse should keep the oxygen-delivery system at least 10 ft away from any open flames to prevent fires. The nurse should store oxygen cylinders by placing them upright. The nurse should check the oxygen level of portable tanks before transporting. The nurse should place an "Oxygen in Use" sign on the patient's door and in the room.
When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority assessment would be: A. Airway patency B. Patient comfort C. Incisional drainage D. Blood pressure and heart rate
A. Airway patency Remember ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system.
The patient has an order for each of the following inhalers. Which of the following should the nurse offer to the patient at the onset of an asthma attack? A. Albuterol (Proventil) B. Beclomethasone (Beclovent) C. Ipratropium bromide (Atrovent) D. Salmeterol (Serevent)
A. Albuterol (Proventil) Albuterol is a short-acting bronchodilator that should initially be given when the patient experiences an asthma attack.
Which medication will the nurse teach a patient with asthma to use when experiencing an acute asthma attack? A. Albuterol (Ventolin) B. Salmeterol (Serevent) C. Theophylline (Theo-Dur) D. Montelukast (Singulair)
A. Albuterol (Ventolin)
A client with acromegaly will most likely experience which symptom? A. Bone pain B. Frequent infections C. Fatigue D. Weight loss
A. Bone pain Acromegaly is an increase in secretion of growth hormone. The growth hormones cause expansion and elongation of the bones. Answers B, C, and D are not directly associated with acromegaly, so they are incorrect.
A client who suffered a brain injury after falling off a ladder has recently developed SIADH. What findings indicate that the treatment he's receiving for SIADH is effective? Select all that apply: A. Decrease in body weight B. Rise in blood pressure and drop in pulse C. Absence of wheezes in the lungs D. Increase in urine output E. Decrease in urine osmolarity
A. Decrease in body weight D. Increase in urine output E. Decrease in urine osmolarity
The nurse is caring for a client with pheochromocytoma. Which of the following must be included in planning the nursing care for this client ? A. Monitor blood pressure frequently, assessing for hypertension. B. Assess only for physical stressors present. C. Collect a random urine sample. D. Prepare the client for chemotherapy to shrink the tumor.
A. Monitor blood pressure frequently, assessing for hypertension. Rationale: Pheochromocytomas are tumors of chromaffin tissues in the adrenal medulla. These tumors which are usually benign produce catecholamines (epinephrine or norepinephrine) that stimulate the sympathetic nervous system. Although many organs are affected, the most dangerous effects are peripheral vasoconstriction and increased cardiac rate and contractility with resultant paroxysmal hypertension. Systolic blood pressure may rise to 200 to 300 mmHg, the diastolic to 150 to 175 mmHg. # 1 is correct because the careful monitoring of blood pressure is essential. Attacks are often precipitated by physical, emotional, or environmental stimuli, so # 2 is incorrect because more than physical stressors are considered. This condition is life threatening and is usually treated with surgery as the preferred treatment. # 3 is incorrect because it is a random sample and not a 24 hour urine collection. Because catecholamine secretion is episodic, a 24-hour urine is a better surveillance method than serum catecholamines. (Pagana & Pagana, 2002). Surgical removal of the tumor(s) by adrenalectomy is the treatment of choice. # 4 is incorrect because surgery would be the treatment usually completed.
A 20 yr old client comes to the clinic because she has experienced a weight loss of 20lbs over the last month, even though her appetite has been "ravenous" and she has not changed her activity level. She's diagnosed with Grave's disease. What other symptoms support the diagnosis of Grave's disease? A. Rapid, bounding pulse B. Bradycardia C. Heat intolerance D. Mild tremors E. Nervousness F. Constipation
A. Rapid, bounding pulse C. Heat intolerance D. Mild tremors E. Nervousness
A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). A. Sharp pleuritic pain that worsens on inspiration B. Crackles over lung bases of affected lung C. Tracheal deviation toward the affected lung D. Worsening dyspnea E. Absent lung sounds to auscultation on affected side
A. Sharp pleuritic pain that worsens on inspiration D. Worsening dyspnea E. Absent lung sounds to auscultation on affected side
Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. "Your urine, sweat, and tears will be orange colored." b. "Read a newspaper daily to check for changes in vision." c. "Take vitamin B6 daily to prevent peripheral nerve damage." d. "Call the health care provider if you notice any hearing loss."
ANS: A Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications.
Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.
ANS: D Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment.
A client newly diagnosed with Addison's disease is giving a return explanation of teaching done by the primary nurse. Which of the following statements indicates that further teaching is necessary? A. "I need to increase how much I drink each day." B. "I need to weigh myself if I think I am losing or gaining weight." C. "I need to maintain a diet high in sodium and low in potassium." D. "I need to take my medications each day."
B. "I need to weigh myself if I think I am losing or gaining weight." The client is at risk for ineffective therapeutic regimen management. Clients with Addison's disease must learn to provide lifelong self-care that involves varied components: medications, diet, and recognizing and responding to stress. Changes in lifestyle are difficult to maintain permanently. The client needs to take the medications on a daily basis. The client needs to perform daily weights to monitor for signs of dehydration. The client needs to maintain a diet high in sodium and low in potassium, as well as maintain an increased fluid intake. # 2 is incorrect because daily weights need to be performed instead of weighing when a problem is suspected.
A client with Addison's disease will most likely exhibit which symptom? A. Hypertension B. Bronze pigmentation C. Hirsutism D. Purple striae
B. Bronze pigmentation a bronze pigmentation is a sign of Addison's disease. Answers A, C, and D are symptoms of Cushing's syndrome, making them incorrect.
The client has emphysema from smoking. During a respiratory system assessment the nurse anticipates finding: A. Abnormal palpation signs in the upper thorax B. Dull sounds on percussion C. A depressed sternum on inspection D. Moist breath sounds on auscultation
B. Dull sounds on percussion
What treatment would the nurse expect to see for diabetes insipidus? A. Diurectics B. IV fluids C. Aldosterone D. Insulin
B. IV fluids
The nurse should expect a client with hypothyroidism to report which health concerns? a. Increased appetite and weight loss b. Puffiness of the face and hands c. Nervousness and tremors d. Thyroid gland swelling
B. Puffiness of the face and hands Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter)
A patient exhibiting exophthalmos most likely suffers from dysfunction of which gland? A. Pancreas B. Thyroid C. Gonads D. Cerebellum
B. Thyroid In Graves' disease, regulatory mechanisms are overridden by an autoimmune process associated with hyperfunction of the thyroid gland. An increase in the number and size of thyroid cells leads to thyroid enlargement (goiter) and an overproduction of thyroid hormone (thyrotoxicosis) with an associated suppression of thyrotropin and TRH. The excess secretion of thyroid hormone contributes to the classic symptoms associated accelerated metabolism, noted above. Infiltrative ophthalmopathy (exophthalmos) occurs in many, but not all cases of Grave's disease. The pancreas is responsible for insulin secretion and blood glucose regulation. The cerebellum is a lob of the brain responsible for balance and equilibrium. Gonads are responsible for sex hormone secretion such as estrogen and testosterone.
Which of the following is a symptom of decreased ADH? A. Weight gain B. Ankle edema C. Dehydration D. Low sodium levels
C. Dehydration
What is a hormone secreted from the posterior lobe of the pituitary gland? A. LH B. MSH C. ADH D. GnRH
C. ADH ADH is secreted from the posterior pituitary. LH comes from the anterior pituitary, MSH from the intermediate. GnRH is released from the hypothalamus.
A client is admitted for treatment of hypoparathyroidism. Based on the client's diagnosis, the nurse would anticipate an order for: A. Potassium B. Magnesium C. Calcium D. Iron
C. Calcium The parathyroid is responsible for calcium and phosphorus absorption. Clients with hypoparathyroidism have hypocalcemia. Answers A, B, and D are not associated with hypoparathyroidism therefore they are incorrect.
A patient states that she has been experiencing a high level of stress lately. Which hormone level is most likely increased due to stress? A. Prolactin B. Calcitonin C. Cortisol D. Oxytocin
C. Cortisol Glucocorticoids, such as cortisol, are released during the stress response. Calcitonin is regulated through the thyroid and not readily influenced by stress. Oxytocin and prolactin are released during pregnancy and breastfeeding, not when stressed.
A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A. "I'll make sure that I rest between activities so I don't get so short of breath." B. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." C. "If I have trouble breathing at night, I'll use two to three pillows to prop up." D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
Which of the following symptoms should be reported by the patient who has diabetes insipidus to the physician? A. Fever B. Bruising C. Increased appetite D. Increased urination
D. Increased urination
The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder should the nurse consider may be related to these results? A. Influenza virus B. Diphtheria bacillus C. Bordetella pertussis D. Mycobacterium tuberculosis
D. Mycobacterium tuberculosis
The nurse understands that which patient factor places the patient at risk for hormonal imbalances? A. Active lifestyle B. High birth weight C. Vitamin supplements D. Sedentary lifestyle
D. Sedentary lifestyle Obesity and a sedentary lifestyle are associated with many hormonal imbalances, such as diabetes and polycystic ovarian syndrome. An active lifestyle has been suggested for prevention of hormone imbalances. Vitamin supplements and high birth weight are not associated with hormonal imbalances.
Which of the following is a symptom of SIADH? A. Dehydration B. Hypernatremia C. Hyperglycemia D. Weight gain
D. Weight gain
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? a) Confusion b) Decreased blood pressure c) Decreased respiratory rate d) Hyperactivity
a) Confusion Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? a) Corticosteroids b) Bronchodilators c) Antibiotics d) Expectorants
a) Corticosteroids In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a) They are low-pitched, soft sounds heard over peripheral lung fields. b) They are loud, high-pitched sounds heard primarily over the trachea and larynx. c) They are medium-pitched blowing sounds heard over the major bronchi. d) They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
a) They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.
The nurse assessing a female client with Cushing's syndrome would expect to note which of the following? a) hirsutism b) hypotension c) hypoglycemia d) pallor
a) hirsutism - An increased production of androgens that accompanies a rise in cortisol levels with Cushing's syndrome produces hirsutism and acne in women. Other clinical findings of Cushing's syndrome include hypertension caused by sodium retention, impaired glucose tolerance or diabetes mellitus caused by cortisol's anti-insulin effect and ability to enhance gluconeogenesis, and skin changes including bruising and purplish red striae caused by protein catabolism
After thyroidectomy, which of the following is the priority assessment to observe laryngeal nerve damage? a) hoarseness of voice b) difficulty in swallowing c) tetany d) fever
a) hoarseness of voice Laryngeal nerve damage is manifested by severe hoarseness of voice of "whispery voice".
A husband of a client with graves' disease expresses concern regarding his wife's health because during the past 3 months she has been experiencing nervousness, inability to concentrate even on trivial tasks, and outbursts of temper. On the basis of this information, which nursing diagnosis would the nurse identify as appropriate for the client? a) ineffective coping b) disturbed sensory perception c) social isolation d) grieving
a) ineffective coping - Frequently, family and friends may report that the client with Graves' disease has become more irritable or depressed. The signs and symptoms in the question are supporting data for the nursing diagnosis of Ineffective coping and are not related to options B, C, and D. The question does not provide data to support options B, C, and D.
The nurse is caring for a patient with severe dehydration. After assessing the urine in the foley catheter what would the nurse expect the patient's urine specific gravity to be? a. 1.065 b. 1.03 c. 1.015 d. 1.025
a. 1.065
Acromegaly is most frequently diagnosed in: a. Middle-aged adults b. Newborns c. Children ages 2 to 5 d. Adults age 65 and older
a. Middle-aged adults Acromegaly results from benign tumors on the pituitary gland that produce excessive amounts of growth hormone. Although symptoms may present at any age, the diagnosis generally occurs in middle-aged persons. Untreated, the consequences of acromegaly include type 2 diabetes, hypertension and increased risk of cardiovascular disease, arthritis and colon polyps.
In a 29-year-old female client who is being successfully treated for Cushing's syndrome, nurse Lyzette would expect a decline in: a. Serum glucose level. b. Hair loss. c. Bone mineralization. d. Menstrual flow.
a. Serum glucose level. Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.
Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus? a. antidiuretic hormone (ADH). b. thyroid-stimulating hormone (TSH). c. follicle-stimulating hormone (FSH). d. luteinizing hormone (LH).
a. antidiuretic hormone (ADH). ADH is the hormone clients with diabetes insipidus lack. The client's TSH, FSH, and LH levels won't be affected.
A patient with acromegaly is treated with a transphenoidal hypophysectomy. Postoperatively, the nurse: a. ensures that any clear nasal drainage is tested for glucose b. maintains the patient flat in bed to prevent cerebrospinal fluid leak c. assists the patient with toothbrushing Q4H to keep the surgical area clean d. encourages deep breathing and coughing to prevent respiratory complications
a. ensures that any clear nasal drainage is tested for glucose Rationale- a transphenoidal hypophysectomy involves entry into the sella turcica through an incision in the upper lip and gingiva into the floor of the nose and the sphenoid sinuses. Postoperative clear nasal drainage with glucose content indicates CSF leakage from an open connection to the brain, putting the patient at risk for meningitis. After surgery, the patient is positioned with the head elevated to avoid pressure on the sella turcica, coughing and straining are avoided to prevent increased ICP and CSF leakage, and although mouth care is required Q4H toothbrushing should not be performed for 7-10post sx.
When caring for a male client with diabetes insipidus, nurse Juliet expects to administer: a. vasopressin (Pitressin Synthetic) b. furosemide (Lasix). c. regular insulin. d. 10% dextrose.
a. vasopressin (Pitressin Synthetic) Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.
When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a) The oxygen must be humidified. b) The rate will be no more than 2 to 3 L/min or less. c) Arterial blood gases will be drawn every 4 hours to assess flow rate. d) The rate will be 6 L/min or more.
b) The rate will be no more than 2 to 3 L/min or less. A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.
Which of the following assessment findings characterize thyroid storm? a) increased body temperature, decreased pulse, and increased blood pressure b) increased body temperature, increased pulse, and increased blood pressure c) increased body temperature, decreased pulse, and decreased blood pressure d) increased body temperature, increased pulse, and decreased blood pressure
b) increased body temperature, increased pulse, and increased blood pressure Thyroid storm is characterized by SNS activation. Thyroid hormones potentiate effects of cathecolamines (epinephrine/norepinephrine). Therefore, all vital signs will be increased.
A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a) Thoracentesis b) Spirometry c) Pulse oximetry d) Peak expiratory flow rate e) Diffusion capacity f) Maximal respiratory pressure
b, c, d Spirometers are used to monitor the health status of patients with respiratory disorders, such as asthma. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with PEFR to monitor airflow. These three tests may be administered by the nurse.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury
b. Diminished breath sounds
Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? a. Diabetic ketoacidosis b. Thyroid crisis c. Hypoglycemia d. Tetany
b. Thyroid crisis Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.
An appropriate nursing intervention for the patient with hyperparathyroidism is to: a. pad side rails as a seizure precaution b. increase fluid intake to 3000 to 4000ml/day c. maintain bed rest to prevent pathologic fractures d. monitor the patient for Trousseau's phenomenon or Chvostek's sign
b. increase fluid intake to 3000 to 4000ml/day (Rationale-A high fluid intake is indicated in hyperparathyroidism to dilute hypercalcemia and flush the kidneys so that calcium stone formation is reduced.)
Of what precautions should a client receiving radioactive iodine-131 be made aware? a.) Drink plenty of fluids, especially those high in calcium. b.) Avoid close contact with children or pregnant women for one week after administration of drug. c.) Be aware of the symptoms of tachycardia, increased metabolic rate, and anxiety. d.) Wear a mask if around children or pregnant women.
b.) Avoid close contact with children or pregnant women for one week after administration of drug. After receiving radioactive iodine-131, you should avoid prolonged, close contact with other people for several days, particularly pregnant women and small children. The majority of the radioactive iodine that has not been absorbed leaves the body during the first two days following the treatment, primarily through the urine. Small amounts will also be excreted in saliva, sweat, tears, vaginal secretions, and feces.
A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a) Pneumonia b) Wheezes c) Pleural effusion d) Tachypnea
c) Pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion).
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? a. Hot, flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breats are taken
c. Chest pain that occurs suddenly
A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a. Infusing I.V. fluids rapidly as ordered b. Encouraging increased oral intake c. Restricting fluids d. Administering glucose-containing I.V. fluids as ordered
c. Restricting fluids To reduce water retention in a client with SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.
To prevent complications in the patient with Cushing syndrome, the nurse monitors the patient for: a. hypotension b. hypoglycemia c. cardiac arrhythmias d. decreased cardiac output
c. cardiac arrhythmias (rationale- electrolyte changes that occur in Cushing syndrome include sodium retention and potassium excretion by the kidney, resulting in hypokalemia, which may lead to cardiac arrhythmias or arrest. Hypotension, hypoglycemia, and decreased cardiac strength and output are characteristic of adrenal insufficiency.)
A nurse provides instructions to a client who is scheduled for a radioactive iodine uptake test. Which statement by the client indicates a need for further instructions? a) the test measures the rate of iodine uptake by my thyroid gland b) I will need to drink a small dose of radioactive iodine before the test c) a 24 hour urine specimen will need to be collected to measure iodine excretion d) I need to minimize close contact with others in my family for a period of 48 hours after the test because of the radioactivity in my system
d) I need to minimize close contact with others in my family for a period of 48 hours after the test because of the radioactivity in my system - The client undergoing a radioactive iodine uptake test needs to be reassured that the amount of radioactive iodine used is very small, that it is not harmful to the client, and that the client will not be radioactive. The other options are correct regarding this diagnostic test.
A clinic nurse is performing an assessment on a client who has hypothyroidism. The nurse would expect to note which clinical manifestation? a) complaints of difficulty sleeping b) complaints of diarrhea c) significant weight loss since the last clinic visit d) complaints of intolerance to cold weather
d) complaints of intolerance to cold weather - An insufficient level of thyroid hormone causes a decrease in metabolic rate and heat production. Intolerance to cold would be noted. Options A, B and C are clinical manifestations of hyperthyroidism.
A nurse is caring for a client with Cushing's syndrome who demonstrates withdrawn behavior. The nurse recognizes that this client's behavior is likely related to which nursing diagnosis? a) deficient diversional activity b) powerlessness c) hopelessness d) disturbed body image
d) disturbed body image - Physical changes in the client's appearance can occur with Cushing's syndrome. Such changes include hirsutism, moon face, buffalo hump, acne, and striae. These changes cause a body image disturbance. Options A, B, and C are not commonly associated with Cushing's syndrome.
A nurse is caring for a client with hyperthyroidism and is instructing the client about dietary measures. The nurse tells the client that it is important to eat foods that are: a) high in bulk and fiber b) low in calories c) low in carbohydrates and fats d) high in calories
d) high in calories The client with hyperthyroidism is usually extremely hungry because of increased metabolism. The client should be instructed to consume a high-calorie diet with six full meals a day. The client should be instructed to eat foods that are nutritious and contain ample amounts of protein, carbohydrates, fats, and minerals. Clients should be discouraged from eating foods that increase peristalsis and thus result in diarrhea, such as highly seasoned, bulky, and fibrous foods.
A client with Addison's disease makes all of the following statements. Which one does the nurse analyze as requiring further discussion? a) I wear a Medic-Alert bracelet at all times b) I need to weigh myself daily and record it c) It is important that I drink enough fluids and increase my salt intake d) my medication doses will not need to be adjusted for any reason
d) my medication doses will not need to be adjusted for any reason The client with Addison's disease is experiencing deficits of mineralocorticoids, glucocorticoids, and androgens. Aldosterone deficiency affects the ability of the nephrons to conserve sodium, so the client experiences sodium and fluid volume deficit. The client needs to manage this problem with daily hormone replacement and increased fluid and sodium intake. Clients are instructed to weigh themselves daily as a means of monitoring fluid volume balance. Glucocorticoids and mineralocorticoids are essential components of the stress response. Additional doses of hormone replacement therapy are needed with any type of physical or psychological stressor. This information needs to be conveyed to the client and requires that the client wear a Medic-Alert bracelet so that health care professionals are aware of this problem if the client were to experience a medical emergency.
A patient with Grave's Disease asks the nurse what caused the disorder. The best response by the nurse is: a. "The cause of Grave's disease is not known, although it is thought to be genetic." b. "It is usually associated with goiter formation from an iodine deficiency over a long period of time." c. "Antibodies develop against thyroid tissue and destroy it, causing a deficiency of thyroid hormones" d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones."
d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones." rationale- The antibodies present in Graves' disease that attack thyroid tissue cause hyperplasia of the gland and stimulate TSH receptors on the thyroid and activate the production of thyroid hormones, creating hyperthyroidism. The disease is not directly genetic, but individuals appear to have a genetic susceptibility to become sensitized to develop autoimmune antibodies. Goiter formation from insufficient iodine intake is usually associated with hypothyroidism.
