CHA Exam 2 Review

A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage?

A yellow edge around nasal discharge

Which treatment intervention should be provided to a client diagnosed with Cushing's disease?

Decrease blood glucose levels

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify?

Deep and rapid respirations

Which clinical manifestations in a client indicate hyperfunctional thyroid gland? Select all that apply.

Diarrhea Weight loss

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake?

Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes?

Hyperglycemia and urine negative for ketones

A nurse is caring for a client admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?

Hypoglycemia and hypotension

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply.

Increased heart rate Increased temperature

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.

Increased serum calcium Decreased serum cortisol Decreased serum sodium

An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should the nurse include in the teaching plan? Select all that apply.

Insulin therapy Blood glucose monitoring Adherence to the treatment regimen

A nurse is teaching the parents of an 8-year-old child who is taking a high dose of oral prednisone for asthma. What critical information about prednisone will be included?

It should be stopped gradually.

The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client?

Kussmaul respirations

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply.

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse

An arterial blood gas report indicates the client's pH is 7.25, PCO 2 is 35 mm Hg, and HCO 3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?

Metabolic acidosis

A client is scheduled for an adrenalectomy. What does the nurse expect that the plan of care will include?

Parenteral corticosteroids

Which does the nurse state is a secondary cause of adrenal insufficiency?

Pituitary tumors

In anticipation of a client returning to their room following a subtotal thyroidectomy, what intervention would be highest priority for the nurse to perform?

Place a tracheostomy set at the bedside.

What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply.

Providing adequate fluids within easy reach Assessing for and reporting changes in neurological status Monitoring for constipation, weight loss, hypotension, and tachycardia

A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, what will the nurse include in the teaching?

Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone.

The nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which finding in the client is consistent with the diagnosis?

Retention of water

A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experiencing a sudden fall in the blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing?

Somogyi effect

The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply.

The client should obtain a finger stick blood glucose reading before each meal. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan should include sick day rules.

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices?

They help the venous blood return to the heart.

A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client?

Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T 3)

A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply.

Truncal obesity Sleep disturbance Thin arms and legs

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate?

Arterial insufficiency

When caring for a client with venous insufficiency, the nurse would implement which nursing measure?

Elevate the client's legs above heart level.

Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take?

Encourage the client to take deep, cleansing breaths.

A nurse is planning an evening snack for a child receiving NPH insulin. What is the reason for this nursing action?

Nourishment helps counteract late insulin activity.