Endo - Sem 3 Nclex
The nurse provides dietary instructions to a pt with DM regarding the rx diabetic diet. Which statement made by the pt indicates the need for further teaching?
"I need to buy special dietetic foods."
The nurse is reinforcing home care instructions to a pt with a dx of Cushing's syndrome. Which pt statement reflects a need for further teaching?
"I need to read the labels on any OTC meds I purchase."
The nurse is assigned to care for a pt at home who has a dx of type 1 DM. When the nurse arrives to care for the pt, the pt tells the nurse that she has been vomiting & has diarrhea. Which additional statement by the pt indicates a need for further teaching?
"I need to stop my insulin." * Rationale: When a pt with DM is unable to eat normally because of illness, the pt should still take the rx insulin or oral med. Additional fluids should be consumed & a call placed to the HCP. The pt should monitor the blood glucose levels q4-6hrs
The nurse has reinforced instructions about measuring blood glucose levels to a client newly dx with DM. The nurse determines that the pt understands the procedure when making which most accurate statement?
"I should check my blood glucose level before eating each meal, regardless of how much I eat."
When the nurse is reinforcing instructions to a pt who has been newly dx with type 1 DM, which statement by the pt would indicate that teaching has been effective?
"I will notify my HCP if my blood glucose level is consistently greater than 250 mg/dL." * Rationale: During illness, the pt should monitor the blood glucose level, & should notify the HCP if the level is greater than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice
A nurse in an outpatient diabetes clinic is assisting in caring for a pt on insulin pump therapy. Which statement by the pt indicates that a knowledge deficit exists regarding insulin pump therapy?
"Now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis ever happening again."
The nurse in an outpatient diabetes clinic is assisting in caring for a pt on insulin pump therapy. Which statement by the pt indicates that a need for teaching regarding insulin pump therapy?
"Now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis occurring again." * Rationale: All of the statements are correct in regard to insulin pump therapy, except the 1 that mentions insulin reactions & ketoacidosis. Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the pt is subject to the usual complications associated with insulin admin without the use of a pump
The nurse has reinforced instructions to the pt with hyperparathyroidism regarding home care measures r/t exercise. Which statement by the pt indicates a need for further teaching? Select all that apply.
- "I need to limit playing football to only the weekends." - "I should exercise in the evening to encourage a good sleep pattern." * Rationale: The pt should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The pt with hyperparathyroidism should pace activities throughout the day & plan for periods of uninterrupted rest. The pt should plan for at least 30min of walking each day to support calcium movement into the bones. The pt should be instructed to use energy level as a guide to activity
The nurse educator is asking the nursing student to recall the s/s of hypothyroidism. The nurse educator determines that the student understands this d/o if which are included in the student's response? Select all that apply.
- Dry skin - Constipation - Cold intolerance * Rationale: Signs of hypothyroidism include dry skin, hair, & loss of body hair; constipation; cold intolerance; lethargy & fatigue; weakness; muscle aches; paresthesias; wt gain; bradycardia; generalized puffiness & edema around the eyes & face; forgetfulness; menstrual disturbances; cardiac enlargement; & goiter. ** Irritability, palpitations, & wt loss are signs of hyperthyroidism
The nurse is caring for a pt following an adrenalectomy & is monitoring for signs of adrenal insufficiency. Which are s/s r/t adrenal insufficiency? Select all that apply.
- Fear - Weakness - Hypotension - Mental status changes
The nurse should expect to note which interventions in the POC for a pt with hypothyroidism? Select all that apply.
- Instruct the pt about thyroid replacement therapy. - Encourage the pt to consume fluids & high-fiber foods in the diet. - Instruct the pt to contact the HCP if episodes of chest pain occur * Rationale: The CM of hypothyroidism are the result of decreased metab from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones & providing measures to support the s/s r/t a decreased metab. The nurse encourages the pt to consume a well-balanced diet that is low in fat for wt reduction & high in fluids & high-fiber foods to prevent constipation. The pt often has cold intolerance & requires a warm environment. The pt would notify the HCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. Iodine preps are used to tx hyperthyroidism. These meds decrease blood flow through the thyroid gland & reduce the production & release of thyroid hormone
The nurse is reviewing a POC for a pt with Addison's disease. The nurse notes that the pt is at r/f dehydration & suggests NIs that will prevent this occurrence. Which NI is an appropriate component of the POC? Select all that apply.
- Monitoring I&O - Monitoring change in mental status - Encouraging fluid intake of at least 3000 mL/day
The nurse notes in the med record that a pt with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the POC? Select all that apply.
- Monitoring extremities for edema - Monitoring daily weight - Monitoring I&O - Maintaining a low-sodium diet
The nurse is caring for a pt with pheochromocytoma. Which data are indicative of a potential complication associated with this d/o?
Congestion heard on auscultation of the lungs * Rationale: The complications associated with pheochromocytoma include hypertensive retinopathy & nephropathy, myocarditis, heart failure (HF), increased platelet aggregation, & stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs is indicative of heart failure (HF). A urinary output of 50 mL/hr is an appropriate output; the nurse would become concerned if the output were less than 30 mL/hr. A coagulation time of 5 minutes is normal. A BUN level of 20 mg/dL is a normal finding
The nurse is assisting in preparing a care plan for a pt with DM who has hyperglycemia. The nurse should focus on which potential problem for this pt?
Dehydration
The nurse is collecting data on a pt with a dx of hypothyroidism. Which of these behaviors, if present in the client's hx, should the nurse determine as being likely r/t the sx of this d/o?
Depression
The nurse is caring for a pt dx with hyperparathyroidism who is prescribed furosemide (Lasix). The nurse reinforces dietary instructions to the pt. Which is an appropriate instruction?
Drink at least 2-3 L of fluid/day
In planning nutrition for the pt with hypoparathyroidism, which diet would be appropriate?
High calcium & low phosphorus
A pt is brought to the ER with suspected diabetic ketoacidosis (DKA). Which finding should the nurse note as being consistent with this dx?
High serum glucose level & low serum bicarbonate level
The nurse is preparing to reinforce instructions to a pt with Addison's disease regarding diet therapy. The nurse understands that which diet should be rx for this pt?
High sodium, High carb diet
A pt with type 2 DM has a blood glucose of more than 600 mg/dL & is c/o polydipsia, polyuria, weight loss, & weakness. The nurse reviews the HCP's documentation & would expect to note which dx?
Hyperglycemic hyperosmolar state (HHS)
Which s/s should the nurse expect to note when collecting data on a client with Addison's disease?
Hypotension & vomiting
A pt is admitted to the hospital with a dx of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dL. IV insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dL. The nurse who is assisting in caring for the pt obtains which item, anticipating a HCP's rx?
IV infusion containing 5% dextrose * Rationale: During management of DKA, when the blood glucose level falls to 300 mg/dL, the infusion rate is reduced & 5% dextrose is added to maintain a blood glucose level of about 250 mg/dL, or until the pt recovers from ketosis. NPH insulin is not used to tx DKA; 50% dextrose is used to tx hypoglycemia. Phenytoin is not a normal tx measure in DKA
A pt is brought to the ER in an unresponsive state, & a dx of hyperglycemic hyperosmolar state (HHS) is made. The nurse who is assisting with care for the pt obtains which item in preparation for the tx of this syndrome?
IV infusion of NS
The nurse is caring for a postop parathyroidectomy pt. Which would require the nurse's immediate attention?
Laryngeal stridor * Rationale: During the postop period, the nurse carefully observes for signs of hemorrhage, which causes swelling & the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration & expiration that is caused by the compression of the trachea & that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway
The nurse is reinforcing instructions to a pt with DM about blood glucose monitoring & monitoring for signs of hypoglycemia. The nurse should teach the pt that which result is a sign of hypoglycemia?
Less than 50 mg/dL
A pt has been dx with hypoparathyroidism. Which food groups should be included in the diet?
Low in phosphorus & high in calcium
A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the pt the rx vitamin & calcium supplement with which liquid?
Milk
After receiving furosemide (Lasix) 40 mg slow IV push for chest pain related to SOB & generalized edema, the pt responds poorly. The pt has no relief of the chest pain, SOB, or edema & only minimal urine output (less than 40 mL of urine). The HCP is notified, & after reviewing the chart, suspects the pt has syndrome of inappropriate antidiuretic hormone (SIADH). Which findings would lead to this specific diagnosis? Refer to chart.
Minimal responsiveness to furosemide (Lasix) & small cell lung cancer * Rationale: The minimal responsiveness to furosemide (Lasix) combined with the generalized edema, SOB , & hx of small cell lung cancer suggest SIADH. Although HTN & wt gain are common in SIADH, they are also common in other diseases such as heart failure. A seizure d/o does not place a pt at higher r/f SIADH, but a lower sodium level through dilution is common in SIADH. The increased pulse could be a compensatory mechanism for the blood pressure, the retained fluid, & wt gain
The nurse notes that a pt with type 1 DM has lipodystrophy on both upper thighs. Which further info should the nurse obtain from the pt during data collection?
Plan for injection rotation * Rationale: Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic pts when the same injection sites are used for prolonged periods of time. Thus pts are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, & the angle of insulin admin do not produce tissue damage
The nurse is collecting data from a pt who is being admitted to the hospital for a dx workup for primary hyperparathyroidism. The nurse understands that which pt complaint would be characteristic of this d/o?
Polyuria * Rationale: Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis (polyuria). This diuresis leads to dehydration & the pt would lose wt
The nurse is caring for a pt with a dx of hypoparathyroidism. The nurse reviews the pts lab results & notes that the calcium level is extremely low. The nurse should expect to note which s/s on data collection?
Positive Trousseau's sign * Rationale: Hypoparathyroidism is r/t a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this d/o is hypocalcemia. When serum calcium levels are critically low, the pt may exhibit positive Chvostek's &Trousseau's signs, which indicate potential tetany
A pt with DM visits the health care clinic. The pt previously had been well controlled with glyburide (DiaBeta), but recently, the fasting blood glucose has been running 180 to 200 mg/dL. Which med, if added to the pts regimen, may be contributing to the hyperglycemia?
Predinsone
The nurse is collecting data regarding a pt after a thyroidectomy & notes that the pt has developed hoarseness & a weak voice. Which nursing action is appropriate?
Reassure the pt that this is usually a temporary condition
A pt who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action?
Test the drainage for glucose * Rationale: After hypophysectomy, the pt should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected & tested for glucose, indicating the presence of CSF. The HOB should not be lowered to prevent increased ICP. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication
The nurse reviews the nursing care plan of an older pt with diabetic neuropathy of the lower extremities as a result of type 2 DM. The nurse plans care, knowing that which problem has the highest priority for this pt?
The possibility of injury as a result of decreased sensation in the legs & feet * Rationale: The pt with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs & feet. This pt is at r/f tissue injury & for falls as a result of this nervous system impairment
The nurse is monitoring a pt following a thyroidectomy for s/s of hypocalcemia. Which s/s noted in the pt indicates the presence of hypocalcemia?
Tingling around the mouth
The nurse is discussing foot care with a diabetic pt & the spouse. The nurse includes which instruction during this informational session?
Toenails should be cut straight across
The nurse has reinforced home care measures to a pt dx with DM regarding exercise & insulin admin. Which statement by the pt indicates a need for further teaching?
"I should perform my exercise at peak insulin time."
The nurse has just supervised a newly dx DM pt self-inject NPH insulin at 7:30 ᴀᴍ. The nurse reviews the time frames for peak insulin action with the pt, telling the pt to be especially watchful for a hypoglycemic reaction between which time frame?
1:30 ᴘᴍ & 7:30 ᴘᴍ
The nurse is caring for a pt with Addison's disease. The nurse checks the pts VS & determines that the pt has orthostatic hypotension. The nurse determines that this finding r/t which factor?
A decreased secretion of aldosterone
While collecting data on a pt being prepared for an adrenalectomy, the nurse obtains a temp reading of 100.8° F. The nurse analyzes this temp reading as which?
A finding that needs to be reported immediately
The nurse is assigned to assist in caring for a pt admitted to the ER with diabetic ketoacidosis (DKA). Which is the priority nursing action for this pt who is in the acute phase?
Admin Reg IV insulin
The nurse is reinforcing instructions to a pt newly dx with DM regarding insulin admin. The HCP has rx a mixture of NPH & regular insulin. The nurse should stress that which is the 1st step?
Inject air equal to the amount of NPH insulin rx into the vial of NPH insulin
A pt who has been newly dx with DM has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon d/c?
Rotate the insulin injection sites systematically * Rationale: Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be admin at room temp. Injection sites should be systematically rotated from one area to another. The pt should be instructed to give injections in one area, about 1" apart, until the whole area has been used & then to change to another site. This prevents dramatic changes in daily insulin absorption
The nurse is collecting data from a pt newly dx with DM regarding the pts learning readiness. Which pt behavior indicates to the nurse that the pt is not ready to learn?
The pt c/o fatigue whenever the nurse plans a teaching session * Rationale: Px sx can interfere with an individual's ability to learn & can indicate to the teacher that the learner lacks motivation to learn if the sx repeatedly recur when teaching is initiated
A pt with DM is being d/c following tx for hyperglycemic hyperosmolar state (HHS) precipitated by acute illness. The pt states to the nurse, "I will call the doctor next time I can't eat for more than a day or so." The nurse plans care, understanding that which statement accurately reflects this pts level of knowledge?
The pt needs immediate education before d/c
A pt is dx with hyperparathyroidism. The nurse teaching the pt about dietary alterations to manage the d/o tells the pt to limit which food in the diet?
Ice cream
Levothyroxine sodium (Synthroid) is rx for a pt with hypothyroidism. The nurse instructs the pt to take the med:
In the morning *Rationale: Synthetic levothyroxine sodium (Synthroid) increases basal metabolic rate & is used to tx hypothyroidism. It's admin in the am (on an empty stomach) to prevent insomnia
The nurse is providing instructions to a pt newly dx with DM. The nurse gives the pt a list of the signs of hyperglycemia. Which specific signs of this complication should be included on the list?
Increased thirst
Which measure should the nurse anticipate being included in the POC for a pt who has been dx with Graves' disease?
Restful environment
A HCP has rx propylthiouracil (PTU) for a pt with hyperthyroidism, & the nurse assists in developing a plan of care for the pt. Which nursing measure would be included in the plan regarding this med?
S/S of hypothyroidism
The nurse reinforces teaching with a pt with DM regarding differentiating between hypoglycemia & ketoacidosis. The pt demonstrates an understanding of the teaching by stating that glucose will be taken if which sx develops?
Shakiness * Rationale: Shakiness is a sign of hypoglycemia, & it would indicate the need for food or glucose. Fruity breath odor, blurred vision, & polyuria are signs of hyperglycemia
A pt who is managing DM with insulin injections asks the nurse for information about any necessary changes in her diet to avoid hyperinsulinism. Which diet would be appropriate for the pt?
Small frequent meals with protein, fat, & carbs at each meal
A pt with type 1 DM is to begin an exercise program, & the nurse is reinforcing instructions to the pt regarding the program. Which should the nurse include in the instructions?
Take a blood glucose test before exercising * Rational: A blood glucose test performed before exercising provides information to the pt regarding the need to eat a snack 1st. Exercising during the peak times of insulin effect or before mealtime places the pt at r/f hypoglycemia. Insulin should be admin as rx
The nurse is preparing to d/c a pt who has had a parathyroidectomy. When reinforcing instructions to the pt about the rx oral calcium supplement, which information should the nurse include?
Take the calcium 30-60 minutes following a meal.
The nurse has collected data on a pt with DM. Findings include a fasting blood glucose of 130 mg/dL, temp 101° F, pulse of 88bpm, resps of 22 bpm, & a BP of 118/78 mm Hg. Which finding would be of concern to the nurse?
Temp
When caring for a pt who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is essential?
Test the drainage for glucose
A pt with DM who takes insulin is seen in the health care clinic. The pt tells the nurse that after giving the injection, the insulin seems to leak through the skin. The nurse can appropriately determine the problem by asking the pt which?
"Are you rotating the injection site?"
The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this d/o?
"Cushing's disease is characterized by an oversecretion of glucocorticoid hormones." * Rationale: Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones. Addison's disease is characterized by the failure of the adrenal cortex to produce & secrete adrenocortical hormones
The nurse is monitoring a pt who has been newly dx with DM for signs of complications. Which statement made by the pt would indicate hyperglycemia & thus warrant HCP notification?
"I am urinating a lot." * Rationale: The classic sx of hyperglycemia include polydipsia, polyuria, & polyphagia
The nurse is reinforcing d/c teaching with a pt who has Cushing's syndrome. Which statement by the pt indicates that the instructions r/t dietary management were understood?
"I can eat foods that contain potassium" * Rationale: A diet that is low in calories, carbs, & sodium but ample in protein & potassium content is encouraged for a pt with Cushing's syndrome. Such a diet promotes wt loss, the reduction of edema & HTN, the control of hypokalemia, & the rebuilding of wasted tissue
A pt with type 1 DM takes NPH insulin q am & checks the blood glucose level qid. The pt tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL & that she "felt funny." Which statement by the pt indicates an understanding of this occurrence?
"I forgot to take my usual mid-afternoon snack yesterday."
A pt with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the pt indicates a correct understanding of Humulin N insulin & exercise?
"I should not exercise in the late afternoon." * Rationale: A hypoglycemic reaction may occur in response to increased exercise. Pts should avoid exercise during the peak time of insulin. Humulin N insulin peaks at 12-14 hours; therefore, late-afternoon exercise would occur during the peak of the med
The nurse is instructing a pt with Addison's disease about a newly rx med, fludrocortisone acetate (Florinef). Which statement by the pt indicates a need for further teaching?
"I will be glad to gain weight."
The nurse is reinforcing d/c instructions to a pt who had a unilateral adrenalectomy. Which info should be a component of the instructions?
Early signs of a wound infection
A hospitalized pt is newly dx with DM. The pt must take both NPH & Regular insulin for glucose control. The nurse develops a teaching plan to help the pt meet which outcome as a 1st step in managing the disease?
Adjust insulin according to capillary blood glucose levels * There are many learning goals for the pt who is newly dx with DM. The pt must learn dietary control, med management, & proper exercise in order to control the disease. As a first step, the pt learns to adjust med (insulin) according to blood glucose results as rx by the HCP. The pt should then focus on long-term dietary control & wt loss, which will often lead to a decreased need for insulin. At the same time that diet is being controlled, the pt should begin a regular exercise program to aid in wt loss
The nurse is reviewing the rx of a pt dx with DM who was admitted because of an infected foot ulcer. Which HCP's rx supports the tx of this condition?
An increase amount of NPH daily insulin
The nurse is reviewing the postop rx for a pt who had a transsphenoidal hypophysectomy. Which HCP's rx noted on the record indicates the need for clarification?
Apply a loose dressing if any clear drainage is noted.
The nurse is assisting with preparing a teaching plan for the pt with DM regarding proper foot care. Which instruction should be included in the plan of care?
Apply a moisturizing lotion to dry feet, but not between the toes.
The nurse is caring for a pt after a thyroidectomy & monitoring for signs of thyroid storm. The nurse determines that which s/s is indicative that a thyroid storm may be occurring?
BP of 80/60
The nurse caring for a pt who has had a subtotal thyroidectomy reviews the POC & determines which problem is the priority for this pt in the immediate postop period?
Bleeding
A pt with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse reinforces which info in the preop teaching plan for the pt?
Blowing the nose following surgery is prohibited * Rationale: The approach used for this surgery is the oronasal route, specifically where the upper lip meets the gum. The surgeon then uses a route through the sphenoid sinus to get to the pituitary gland. The pt isn't allowed to blow the nose, sneeze, or cough vigorously because these activities could raise ICP. The pt also is not allowed to brush the teeth, to avoid disrupting the surgical site. Alternate methods for performing mouth care are used
The nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dL on an otherwise healthy pt. The nurse tells the pt to do which as a next step?
Call the HCP to have the value rechecked asap
The wife of a pt with DM who takes insulin calls the nurse in a HCP's office about her husband. She states that her husband is sleepy & that his skin is warm & flushed. She adds that his breathing is faster than normal & his pulse rate seems fast. Which action should the nurse tell the wife to do 1st?
Check his blood glucose level * Rationale: The pts s/s are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse should then report to the HCP
The nurse enters the room of a pt with type 1 DM & finds the pt difficult to arouse. The pts skin is warm & flushed, & the pulse & respiratory rate are elevated from the pts baseline. Which action should the nurse implement?
Check the pts capillary blood glucose * Rationale: The nurse must first obtain a blood glucose reading to determine the pts problem. Insulin therapy is guided by blood glucose measurement
Following hypophysectomy, a pt c/o being very thirsty & having to urinate freq. Which is the initial nursing action?
Check the urine specific gravity * Rationale: Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone deficiency. This deficiency is r/t surgical manipulation. The nurse should check the urine for specific gravity & report the results if they are less than 1.005. Urinary glucose & DM is not a concern here. In this situation, increasing fluid intake would require a HCPs rx. The pts complaint would be documented but not as an initial action.
A pt with DM demonstrates acute anxiety when admitted to the hospital for the tx of hyperglycemia. Which intervention would be appropriate to decrease the pts anxiety?
Convey empathy, trust, & respect toward the pt
A pt with a dx of diabetic ketoacidosis (DKA) is being tx in the ER. Which finding should the nurse expect to note as confirming this dx?
Elevated blood glucose & low plasma bicarbonate * Rationale: In DKA, the arterial pH is less than 7.35, plasma bicarbonate is less than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, & ketones are present in the blood & urine. The pt would be experiencing polyuria & Kussmaul's respirations. Coma may occur if DKA is not tx, but coma would not confirm the dx
The nurse is assisting in preparing a POC for the pt with DM & plans to reinforce the pts understanding regarding the s/s of hypoglycemia. Which s/s should the nurse review?
Elevated pulse; shakiness; & cool, clammy skin
A nursing student notes in the med record that a pt with Cushing's syndrome is experiencing body image disturbances. The need for additional education regarding this problem is identified when the nursing student suggests which NI?
Evaluating the pts understanding that the body changes need to be dealt with * Rationale: Evaluating the pts understanding that the body changes that occur in this d/o need to be dealt with is an inappropriate NI
After several dx tests, a pt is dx with diabetes insipidus. The nurse understands that which s/s are indicative of this d/o?
Excessive thirst and urine output * Rationale: Excessive thirst (polydipsia) & excessive urine output (polyuria) are classic dx of diabetes insipidus. The urine is pale in color, & its specific gravity is low. Anorexia & wt loss occur
A pt scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the pts statement, the nurse determines that the pt is experiencing which problem?
Fear about impending surgery
A comatose pt with an admitting dx of diabetic ketoacidosis (DKA) has a blood glucose value of 368 mg/dL, arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, & is positive for serum ketones. The dx is supported by which noted data?
Fruity breath odor * Rationale: Diabetic ketoacidotic coma is usually identified with a fruity breath odor, dry cracked mucous membranes, hypotension, & rapid deep breathing
The nurse is caring for a client with pheochromocytoma. The pt asks for a snack & something warm to drink. Which is the appropriate choice for this pt to meet nutritional needs?
Graham crackers & warm milk
A pt with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse plans care & places highest priority on which potential problem?
Infection * Rationale: The pt with a stab wound has a break in the body's 1st line of defense against infection. The pt with Cushing's disease is at great r/f infection because of excess cortisol secretion & subsequent impaired antibody function & decreased proliferation of lymphocytes. The pt may also have a potential for the problems listed in the other options, but these are not the highest priority at this time
The nurse is collecting data on a pt admitted to the hospital with a dx of myxedema. Which data collection technique would provide data necessary to support the admitting dx?
Inspection of facial features
A client has an endocrine system dysfunction of the pancreas. The nurse anticipates that the client will exhibit impaired secretion of which substance?
Insulin
The nurse is reinforcing dietary instructions to a pt newly dx with DM. The nurse accurately instructs the pt with which statement?
It is best to eat meals at approximately the same time each day
A pt with newly dx Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the pt about this sx, the nurse should incorporate which knowledge?
It may slowly improve with tx of the d/o
A pt recently dx with DM requiring insulin tells the clinic nurse that he's traveling by air throughout the next week. The pt asks the nurse for any suggestions about managing the d/o while traveling. Which action should the nurse tell the pt to do?
Keep snacks in carry-on luggage to prevent hypoglycemia during the flight.
The nurse is reinforcing instructions with a pt with DM who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize?
Monitor blood glucose levels frequently * Pt education after DKA should emphasize the need for home glucose monitoring 4-5x/day. It is also important to instruct the pt to notify the HCP when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The pt should eat well-balanced meals with snacks, as rx
Which nursing action would be appropriate to implement when a pt has a dx of pheochromocytoma?
Monitor the pts BP * Rationale: HTN is the major symptom that is associated with pheochromocytoma. The BP status is monitored by taking the pts BP. Glycosuria, wt loss, & diaphoresis are also s/s of pheochromocytoma, but HTN is the major symptom.
Which nursing measure would be effective in preventing complications in a pt with Addison's disease?
Monitoring the blood glucose * Rationale: The decrease in cortisol secretion that characterizes Addison's disease can result in hypoglycemia. Therefore, monitoring the blood glucose would detect the presence of hypoglycemia so that it can be tx early to prevent complications. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia
The nurse is reviewing a HCP's rx for a pt with newly dx, untreated hypothyroidism. Which med rx for the pt should the nurse question & verify?
Morphine Sulfate * Rationale: The pt with hypothyroidism experiences fatigue, lethargy, & increased somnolence. The decreased metabolism & O2 consumption is manifested by a slow HR, decreased cardiac output, & decreased BP. Levothyroxine, a thyroid hormone, is a component of therapy. Stool softeners such as docusate sodium are rx to promote defecation. Morphine sulfate would further depress bodily functions. Atenolol is used with caution in pts with hyperthyroidism
A pt with Graves' disease has exophthalmos & is experiencing photophobia. Which intervention would best assist the pt with this problem?
Obtain dark glasses for the pt
The nurse caring for a pt scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists in developing a POC for the pt. The nurse suggests including which specific information in the preop teaching plan?
Toothbrushing will not be permitted for at least 2 weeks following surgery.
Which pt complaint should alert the nurse to a possible hypoglycemic reaction?
Tremors & double vision * Rationale: Decreased blood glucose levels produce automatic nervous system sx, which are classically manifested as nervousness, irritability, & tremors
During data collection on a postop pt who has undergone hypophysectomy, the pt c/o thirst & freq urination. Knowing the expected complication of this surgery, the nurse should check which parameter next?
Urine specific gravity
The nurse is caring for a ptwith pheochromocytoma. The ptis scheduled for an adrenalectomy. During the preoperative period, the priority nursing action should be to monitor which criterion?
VS * Rationale: HTN is the hallmark of pheochromocytoma. Severe HTN can precipitate a stroke or sudden blindness. Although all of the options are accurate NIs for the pt, the priority nursing action is to monitor the VS, particularly the BP
