Exam I CAQs
For which client response should the nurse monitor when assessing for complications of hyperparathyroidism? A. Tetany C. Seizures B. Bone pain D. Graves disease
B. Bone pain REASONING: Hyperparathyroidism causes calcium release from the bones, leaving them porous, weak, and painful. Tetany is the result of low calcium levels; in this condition the serum calcium level is increased. Seizures are caused by increased neural activity, a condition not related to this disease. Graves disease is the result of increased thyroid, not parathyroid, activity.
A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? A. Constipation B. Muscle spasms C. Hypoactive reflexes D. Increased specific gravity
B. Muscle spasms REASONING: Removal of the parathyroids causes hypocalcemia and associated neuromuscular irritability. Constipation is a sign of hypercalcemia. Hypoactive reflexes are signs of hypercalcemia. Increased specific gravity is a sign of fluid volume deficit.
Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. A. Lethargy B. Tachycardia C. Weight gain D. Constipation E. Exophthalmos
B. Tachycardia E. Exophthalmos REASONING: Tachycardia is associated with hyperthyroidism and is caused by the increase in the basal metabolic rate. Exophthalmos is associated with hyperthyroidism and results from accumulation of fluid behind the eyeball. Lethargy is associated with hypothyroidism; hyperactivity occurs with hyperthyroidism. Weight gain occurs with hypothyroidism; weight loss occurs with hyperthyroidism because of the high metabolic rate. Constipation is associated with hypothyroidism; frequent loose stools occur with hyperthyroidism.
A client with adrenal insufficiency reports feeling weak and dizzy, especially in the morning. What should the nurse determine is the most probable cause of these symptoms? A. A lack of potassium B. Postural hypertension C. A hypoglycemic reaction D. Increased extracellular fluid volume
C. A hypoglycemic reaction REASONING: Deficiency of glucocorticoids causes hypoglycemia in the client with Addison disease. Clinical manifestations of hypoglycemia include nervousness; weakness; dizziness; cool, moist skin; hunger; and tremors. Hypokalemia is evidenced by nausea, vomiting, muscle weakness, and dysrhythmias. Weakness with dizziness on arising is postural hypotension, not hypertension. An increased extracellular fluid volume is evidenced by edema, increased blood pressure, and crackles.
A client is admitted to the hospital with diabetic ketoacidosis. The nurse concludes that the client's elevated ketone level is caused by incomplete oxidation of which nutrient? a. Fats b. Protein c. Potassium d. Carbohydrates
a. Fats REASONING: Incomplete oxidation of fat results in fatty acids that further break down to ketones. Protein metabolism produces nitrogenous waste, causing elevated blood urea nitrogen (BUN), not ketones. Potassium is not oxidized; potassium is not directly associated with ketones. Carbohydrates do not contain fatty acids that are broken down into ketones.
The major nursing concern when caring for a client with the diagnosis of hyperthyroidism is: a. Monitoring for hypoglycemia b. Protecting visitors and staff from radiation exposure c. Providing foods to increase appetite d. Arranging for sufficient rest periods
d. Arranging for sufficient rest periods Promotion of rest to reduce metabolic demands is a challenging but essential task for a client who has hyperthyroidism. With hyperthyroidism, glucose tolerance is decreased, and the client is hyperglycemic. There is no indication that radioactive iodine has been given; therefore, the client does not emit radiation. The client will have an increased appetite.
A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this client's plan of care? A. Ensuring a large fluid intake B. Providing a high-calcium diet C. Instituting seizure precautions D. Encouraging complete bed rest
A. Ensuring a large fluid intake REASONING: Fluids help prevent the formation of renal calculi associated with high levels of serum calcium. Additional calcium intake may increase the already high levels of serum calcium. Seizures are associated with low, not high, levels of serum calcium. Bed rest is contraindicated because it accelerates bone destruction.
A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply. A. Headache B. Confusion C. Extreme thirst D. Profuse sweating E. Increased urination
A. Headache B. Confusion D. Profuse sweating REASONING: Neurologic responses occur when there is an insufficient supply of glucose to the brain, thus causing clinical manifestations such as headache and confusion. Profuse sweating is a classic sign of hypoglycemia. This is triggered by lack of glucose to the nerve cells. Thirst (polydipsia) is a classic symptom of hyperglycemia. Increased urination (polyuria) is a classic sign of hyperglycemia.
The nurse provides care to the client with diabetes insipidus (DI) following head injury by: Select all that apply. A. Providing adequate fluids within easy reach B. Reporting an increasing urine specific gravity C. Administering prescribed demeclocycline (Declomycin) D. Assessing for and reporting changes in neurological status E. Monitoring for constipation, weight loss, hypotension, and tachycardia
A. Providing adequate fluids within easy reach D. Assessing for and reporting changes in neurological status E. Monitoring for constipation, weight loss, hypotension, and tachycardia REASONING: Diabetes insipidus is a condition resulting in underproduction of antidiuretic hormone. The focus of care is on maintaining fluid and electrolyte balance. Oral fluids must be easily accessible at the bedside to balance urinary losses and prevent severe dehydration. The nurse monitors for, and reports, changes in neurological status associated with hypernatremia and high serum osmolality. Constipation and weight loss indicate fluid volume deficit and must be reported. Hypotentsion and tachycardia are signs of impending shock. Massive polyuria results in dilute urine. Decreasing urine specific gravity must be reported. Demaclocycline decreases the renal response to antidiuretic hormone (ADH) or endogenous vasopressin. In diabetes insipidus, ADH production is decreased. The primary pharmacologic treatment for diabetes insipidus, then, is replacement of ADH with an exogenous vasopressin, such as desmopressin acetate (DDAVP). Administering demaclocycline to block the renal response to ADH in the client with decreased ADH production would be deleterious. Demeclocycline is used to treat syndrome of inappropriate antidiuretic hormone (SIADH), a condition of overproduction of ADH.
A client is being discharged after having a total thyroidectomy. Which instruction would be most important for the nurse to include? A. Take thyroid replacement medications as prescribed. B. Be aware of signs and symptoms of dehydration. C. Avoid all over the counter medications. D. Report signs of hypoglycemia.
A. Take thyroid replacement medications as prescribed. REASONING: Long term thyroid replacement is prescribed after surgery to replace the thyroid's natural function. Although teaching signs and symptoms of dehydration is a health promotion strategy, it is not the priority. Clients should not be encouraged to avoid all over the counter medications, but instructed to discuss contraindications with their health care provider or pharmacy. Low blood glucose is not attributed to this procedure.
A client undergoes pituitary surgery via the transsphenoidal route. Which foods should the nurse instruct the client to avoid after surgery? Select all that apply. A. Toast B. Celery C. Shellfish D. Grapefruit E. Aged cheese
A. Toast B. Celery REASONING: Because roughage, such as toast, can irritate the surgical wound and lead to hemorrhage, toast is contraindicated in the postsurgical period of transsphenoidal surgery. Celery is a form of roughage that can irritate the surgical wound and jeopardize the surgical site. Shellfish is not contraindicated in the diet of a client who has undergone transsphenoidal surgery because it is nonirritating. Grapefruit is not contraindicated in the diet of a client who has undergone transsphenoidal surgery because it will not irritate the tissue. Aged cheese is not contraindicated in the diet of a client who has undergone transsphenoidal surgery because it is nonirritating.
A client has a new diagnosis of hyperthyroidism. Which skin conditions should the nurse expect when performing a physical assessment? Select all that apply A. Warm B. Moist C. Pale D. Smooth E. Coarse F. Dry
A. Warm B. Moist D. Smooth REASONING: Hyperfunction of the thyroid gland causes diaphoresis, making the skin moist, as well as skin that is smooth and warm. Pale, coarse, and dry skin is found with hypothyroidism.
A client with a diagnosis of Graves disease refuses to have radioactive iodine (RAI) therapy, and a subtotal thyroidectomy is performed. What should the nurse do postoperatively to reduce the risk of thyroid storm? A. Provide a high-calorie diet. B. Prevent infection at the surgical site. C. Encourage postoperative breathing exercises. D. Demonstrate how to support the neck after surgery.
B. Prevent infection at the surgical site. REASONING: Conditions such as trauma and infection can precipitate thyroid storm (thyroid crisis, thyrotoxic crisis). A high-calorie diet does not prevent crisis; it restores glycogen reserves depleted by an increased metabolic rate. Postoperative breathing exercises prevent respiratory complications, not thyroid storm. Learning how to support the neck after surgery limits tension on the suture line, thereby decreasing the risk of hemorrhage, not thyroid storm.
A client with type 1 diabetes mellitus has a fingerstick glucose level of 258 mg/dL at bedtime. A prescription for sliding scale regular insulin (Novolin R) exists. What should the nurse do? A. Call the health care provider. B. Encourage the intake of fluids. C. Administer the insulin as prescribed. D. Give the client a half cup of orange juice.
C. Administer the insulin as prescribed. REASONING: A value of 258 mg/dL is above the expected range of 70 to 100 mg/dL; the nurse should administer the regular insulin as prescribed. Calling the health care provider is unnecessary; a prescription for insulin exists and should be implemented. Encouraging the intake of fluids is insufficient to lower a glucose level this high. Giving the client a half cup of orange juice is contraindicated because it will increase the glucose level further; orange juice, a complex carbohydrate, and a protein should be given if the glucose level is too low.
After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone. For which manifestation of excessive levels of antidiuretic hormone (ADH) should the nurse assess? A. Increased blood urea nitrogen (BUN) C. Decreased urine output B. Decreased specific gravity D. Increased serum sodium level
C. Decreased urine output REASONING: ADH causes water retention, resulting in decreased urine output. Blood volume may increase, causing dilution of nitrogenous wastes in the blood. ADH acts on nephrons to cause water to be reabsorbed from glomerular filtrate, leading to an increased specific gravity of urine. The client is overhydrated so that serum sodium is decreased.
A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? A. Fluid loss B. Glycosuria C. Kussmaul respirations D. Increased blood glucose level
C. Kussmaul respirations REASONING: Kussmaul respirations occur in diabetic coma as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.
Which clinical manifestation should a nurse expect a client with diabetes insipidus to exhibit? A. Increased blood glucose B. Decreased serum sodium C. Increased specific gravity D. Decreased urine osmolarity
D. Decreased urine osmolarity REASONING: Insufficient antidiuretic hormone (ADH) decreases water uptake by the kidney tubules, resulting in very dilute urine with low osmolarity. Diabetes insipidus does not affect glucose levels. Serum sodium levels increase because of hemoconcentration. Specific gravity decreases with dilute urine.
A client with a head injury has been receiving dexamethasone (Decadron). The health care provider plans to reduce the dosage gradually and to continue a lower maintenance dosage. Which effect associated with the gradual dosage reduction of the drug should the nurse explain to the client? A. Builds glycogen stores in the muscles B. Produces antibodies by the immune system C. Allows the increased intracranial pressure to return to normal D. Promotes return of cortisone production by the adrenal glands
D. Promotes return of cortisone production by the adrenal glands REASONING: Hormone therapy must be withdrawn slowly to allow the adrenal glands to adjust and resume production of their hormone. Building glycogen stores in the muscles, producing antibodies by the immune system, and allowing the increased intracranial pressure to return to normal are not reasons for the gradual withdrawal of dexamethasone.
A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. The nurse should: a. Notify the health care provider b. Increase the intravenous (IV) flow rate c. Raise the head of the bed d. Place the client in the Trendelenburg position
a. Notify the health care provider REASONING: Cerebral compression affects pyramidal tracts, resulting in flexion (decorticate) rigidity and cranial nerve injury, which cause pupil dilation. Meningeal irritation will not produce postural or pupillary changes without cerebral compression. Collection of blood between the dura and arachnoid will not cause postural or pupillary changes without cerebral compression. Medullary compression results in alterations in vital signs.
A client who is feeling increasingly tired seeks medical care. Type 1 diabetes is diagnosed. The nurse explains that the increased fatigue is the result of: a. Increased metabolism at the cellular level b. Increased glucose absorption from the intestine c. Decreased production of insulin by the pancreas d. Decreased glucose secretion into the renal tubules
c. Decreased production of insulin by the pancreas REASONING: Insulin facilitates transport of glucose across the cell membrane to meet metabolic needs and prevent fatigue. With diabetes there is decreased cellular metabolism because of the decrease in glucose entering the cells. Glucose is not absorbed from the intestinal tract by the cells; fatigue is caused by decreased, not increased, cellular levels of glucose. Filtration and excretion of glucose by the kidneys do not regulate energy levels; if insulin production is adequate, glucose does not spill into the urine.
A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis? a. Decreased serum glucose levels b. Decreased serum calcium levels c. Increased blood urea nitrogen levels d. Increased serum bicarbonate levels
c. Increased blood urea nitrogen levels REASONING: With diabetic ketoacidosis blood urea nitrogen level generally is increased because of dehydration. With diabetic ketoacidosis, the serum glucose levels are generally above 300 mg/dL. The calcium level is unrelated to diabetic ketoacidosis. Serum bicarbonate levels are below 15 mEq/L.
A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify? A. Retention of sodium and water B. Hypotension and a rapid, thready pulse C. Increased fatty deposition in the extremities D. Hypoglycemic episodes in the early morning
A. Retention of sodium and water REASONING: There are increased levels of steroids and aldosterone causing sodium and water retention in clients with Cushing syndrome. Hypertension, not hypotension, is expected because of sodium and water retention. The extremities will be thin; subcutaneous fat deposits occur in the upper trunk, especially the back between the scapulae. Hyperglycemia, not hypoglycemia, occurs because of increased secretion of glucocorticoids. Hyperglycemia is sustained and not restricted to the morning hours.
Blood studies are being performed on a client with the potential diagnosis of hyperparathyroidism. What serum blood level should the nurse expect to be decreased when reviewing this client's hematologic studies? A. Calcium B. Chloride C. Phosphorus D. Parathormone
C. Phosphorus REASONING: Because of its inverse relationship with calcium, when serum calcium levels increase, serum phosphorous levels decrease (greater than 3 mg/dL; greater than 0.1 mmol/L). Serum calcium levels will increase because of the action of elevated levels of serum parathormone; serum calcium levels usually exceed 10 mg/dL (2.50 mmol/L). Serum chloride levels will increase, not decrease, with hyperparathyroidism. Parathormone, produced in the parathyroid gland, will increase with hyperparathyroidism.
A man walks into the emergency room (ER) with sunglasses on and tells the nurse that he fell off a ladder and hit his head and was unconscious for a few minutes. What is the most appropriate next question the nurse should ask the client? a. "Did you pass out?" b. "Can you take off your sunglasses?" c. "Are you injured anywhere else?" d. "How many feet did you fall?"
b. "Can you take off your sunglasses?" REASONING: The nurse cannot quickly assess the client for raccoon eyes unless the sunglasses are removed. Raccoon eyes is periorbital ecchymosis around the eyes. If bilateral, it is highly suggestive of basilar skull fracture. It is caused by rupture of the meninges causing the venous sinuses to bleed into the arachnoid villi and cranial sinuses, resulting in pooling of blood around the eyes. It most often is associated with fractures of the anterior cranial fossa and requires immediate attention. It is also important to assess for any loss of consciousness, other injuries, and the height of the fall. However, visually assessing the client comes first.
A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? a. Nausea b. Lethargy c. Sunset eyes d. Hyperthermia
b. Lethargy REASONING: Lethargy is an early sign of a changing level of consciousness; it is one of the first signs of increased intracranial pressure. Nausea is a subjective symptom, not a sign, that may be present with increased intracranial pressure. Sunset eyes are a late sign of increased intracranial pressure that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased intracranial pressure that occurs as compression of the brainstem increases.
Which nursing intervention is the priority when a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)? a. Providing oxygen b. Encouraging carbohydrates c. Administering fluid replacement d. Teaching facts about dietary principles
c. Administering fluid replacement REASONING: As a result of osmotic pressures created by an increased serum glucose level, the cells become dehydrated; the client must receive fluid and then insulin. Oxygen therapy is not necessarily indicated. Carbohydrates will increase the blood glucose level, which is already high. Although dietary instruction may be appropriate later, such instruction is inappropriate during the crisis.
A client with a head injury has a fixed, dilated right pupil, responds only to painful stimuli, and exhibits flexion (decorticate) posturing. What should the nurse conclude that these clinical findings indicate? a. Meningeal irritation b. Subdural hemorrhage c. Cerebral compression d. Medullary compression
c. Cerebral compression REASONING: Cerebral compression affects pyramidal tracts, resulting in flexion (decorticate) rigidity and cranial nerve injury, which cause pupil dilation. Meningeal irritation will not produce postural or pupillary changes without cerebral compression. Collection of blood between the dura and arachnoid will not cause postural or pupillary changes without cerebral compression. Medullary compression results in alterations in vital signs.
An obese client is diagnosed with diabetes. What increased physiological response to excessive weight should the nurse include when explaining the need for weight loss? a. Fatty acid storage b. Glucose oxidation c. Insulin requirements d. Cellular entry of glucose
c. Insulin requirements REASONING: Obesity causes insulin resistance at the cellular level, so more insulin is required for transfer of glucose across cell membranes. Fatty acid metabolism is altered. Fatty acids break down; storage decreases. With obesity, oxidation of glucose decreases and insulin needs increase. Obesity causes peripheral cellular resistance to glucose entry into cells.
A nurse adds 20 mEq of potassium chloride to the intravenous (IV) solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug? a. Treat hyperpnea. b. Prevent flaccid paralysis. c. Replace excessive losses. d. Treat cardiac dysrhythmias.
c. Replace excessive losses. REASONING: Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore, potassium, along with the replacement fluids, is needed. Potassium will not correct hyperpnea. Flaccid paralysis does not occur in diabetic ketoacidosis. Considering the relationship between insulin and potassium, treatment with KCl is prophylactic, preventing the development of dysrhythmias.
A client is scheduled to have a thyroidectomy for cancer of the thyroid. What specific instruction about postoperative care should the nurse provide the client during preoperative teaching? a. Cough and deep breathe every hour. b. Perform range-of-motion exercises of the head and neck. c. Support the head with the hands when changing position. d. Apply gentle pressure against the incision when swallowing.
c. Support the head with the hands when changing position. REASONING: Supporting the head with the hands when changing position relieves tension on the incision and limits the risk of dehiscence. Coughing should be avoided during the early postoperative period to prevent trauma to the operative site. Performing range-of-motion exercises of the head and neck should be avoided until advised by the health care provider, usually after sutures or skin clips have been removed. Pressure against the operative area is not necessary to promote integrity of the incision, and it may inhibit swallowing.
A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan as a means of encouraging this client to modify dietary intake? a. Increased amounts of potassium are needed to replace renal losses. b. Increased protein is needed to heal the adrenal tissue and thus cure the disease. c. Supplemental vitamins are needed to supply energy and assist in regaining the lost weight. d. Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.
d. Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium. REASONING: Lack of mineralocorticoids (aldosterone) leads to loss of sodium ions in the urine and subsequent hyponatremia. Potassium intake is not encouraged; hyperkalemia is a problem because of insufficient mineralocorticoids. Increasing protein is needed to heal the adrenal tissue and thus cure the disease caused by idiopathic atrophy of the adrenal cortex; tissue repair of the gland is not possible. Vitamins are not directly energy-producing, nor will they help the client gain weight.
A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous (IV) fluids followed by an IV bolus of regular insulin. The nurse anticipates that the health care provider will prescribe a continuous infusion of: a. Novolin L insulin. b. Novolin R insulin. c. Novolin N insulin. d. Novolin U insulin.
b. Novolin R insulin. REASONING: Regular insulin is the only insulin that is administered intravenously. Novolin L insulin cannot be administered intravenously. Novolin N insulin cannot be administered intravenously. Novolin U insulin cannot be administered intravenously.
A nurse is caring for a client who just had a thyroidectomy. For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during surgery? A. Tetany B. Myxedema C. Hypovolemic shock D. Adrenocortical stimulation
A. Tetany REASONING: Parathyroid removal eliminates the body's source of parathyroid hormone (parathormone), which increases the blood calcium level. The resulting low body fluid calcium affects muscles, including the diaphragm, resulting in dyspnea, asphyxia, and death. Loss of the thyroid gland will upset thyroid hormone balance and may cause myxedema. The parathyroids are not involved in regulating plasma volume; the pituitary and adrenal glands are responsible. The parathyroids do not regulate the adrenal glands.
Which health problem should the nurse consider is most likely to precipitate acute hypoglycemia in a client? A. Liver disease B. Hypertension C. Hyperthyroidism D. Cushing syndrome
A. Liver disease REASONING: Clients with liver disease have a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen (glycogenolysis). Hypertension is not related to a decreased serum glucose level. Hyperthyroidism is not related to a decreased serum glucose level. Cushing syndrome causes hyperglycemia.
The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply. A. Wear shoes when out of bed. B. Soak the feet in warm water daily. C. Dry between the toes after bathing. D. Remove corns as soon as they appear. E. Use a heating pad when the feet feel cold.
A. Wear shoes when out of bed. C. Dry between the toes after bathing REASONING: Wearing shoes protects the feet from trauma; they should fit well and should be worn over clean socks. Drying between the toes after bathing prevents maceration and skin breakdown, thus maintaining skin integrity. Soaking the feet is contraindicated because it can cause macerations and skin breakdown, which allow a portal of entry for pathogenic organisms. Clients should not self-treat corns, calluses, warts, or ingrown toenails because of the potential for trauma and skin breakdown; these conditions should be treated by a podiatrist. Use of a heating pad, hot water bottle, or hot water is contraindicated because of the potential for burns; diabetic neuropathy, if present, does not allow the client to accurately evaluate the extremes of temperature.
The nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these, if found, are signs of Cushing disease? Select all that apply. A.Round face B. Dependent edema in the feet and ankles C. Increased fatty deposition in the extremities D. Thin, translucent skin with bruising E. Increased fatty deposition in the neck and back
A.Round face B. Dependent edema in the feet and ankles D. Thin, translucent skin with bruising E. Increased fatty deposition in the neck and back REASONING: Changes in fat distribution may result in fat pats on the neck, back, shoulders, and a round face. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thin because of muscle wasting and weakness, not increased by fatty deposition. Hypertension, not hypotension, is expected because of sodium and water retention.
A client is admitted to the hospital with a diagnosis of cancer of the thyroid gland, and a thyroidectomy is performed. What should the nurse do during the first six to eight hours after the surgery? A. Place two pillows behind the client's head. B. Monitor for the complication of tetany resulting from hypocalcemia. C. Assess the sides and back of the client's neck for evidence of bleeding. D. Encourage the client to perform deep-breathing and coughing exercises.
C. Assess the sides and back of the client's neck for evidence of bleeding. REASONING:In a back-lying (supine) position blood will flow with gravity down the sides of the neck and not be seen. Positioning two pillows behind the client's head flexes the neck excessively; this increases tension on the suture line and may inhibit the passage of gases through the oral, pharyngeal, and tracheal areas. A small pillow behind the head keeps the head and neck in functional alignment and limits tension on the suture line. Although monitoring for the complication of tetany resulting from hypocalcemia may be a complication of this surgery, tetany will not occur during the first eight hours after surgery. Although deep breathing should be encouraged, coughing should not be encouraged during the first 24 to 48 hours, to limit stress on the suture line.
A client undergoes removal of a pituitary tumor through a transsphenoidal approach. Postoperatively the nurse should: A. Provide oral hygiene and include brushing the teeth B. Encourage the client to deep breathe and cough frequently C. Maintain the head of the bed at a 30 degree angle continuously D. Continue giving nothing by mouth until the nasal packing is removed
C. Maintain the head of the bed at a 30 degree angle continuously REASONING: Maintaining the head of the bed at a 30 degree angle continuously decreases pressure on the sella turcica and promotes venous return, thus limiting cerebral edema. Gentle oral hygiene is performed, excluding brushing of teeth, to prevent trauma to the surgical site. Although deep breathing is encouraged, initially coughing is discouraged to prevent increasing intracranial pressure. There is no need to limit oral fluids because of the presence of nasal packing.
The client is admitted to the hospital with a large goiter, and a thyroidectomy is performed. What should the nurse do during the first four hours after the surgery? Select all that apply A. Ensure that the client lies flat. B. Monitor vital signs every hour. C. Monitor for stridor or dyspnea . D. Monitor for the signs and symptoms of tetany. E. Assess the sides and back of the client's neck for evidence of bleeding.
C. Monitor for stridor or dyspnea . E. Assess the sides and back of the client's neck for evidence of bleeding. REASONING: After a thyroidectomy, it is critical to monitor for stridor, dyspnea, or other symptoms of acute airway obstruction that may result postoperatively. It is important to inspect the neck dressing, as well as the sides of the neck and behind the neck, for blood that may drain in that direction by gravity. The client needs to be placed in a semi-Fowler position to decrease tension on the suture line. Vital signs need to be monitored every 15 minutes until the client is stable, then every 30 minutes for 24 hours. Although this may be a complication of this surgery, tetany will not occur during the first 4 hours after surgery.
A client who is 60 pounds more than the ideal body weight is admitted to the hospital with a diagnosis of type 1 diabetes. Which concept should the nurse include in teaching about diabetes when discussing strategies to lose weight? a. Obesity leads to insulin resistance b. Surplus fat causes excretion of insulin c. Fat cells absorb insulin and prevent its circulation to other cells d. Lipids accumulate in the pancreas and interfere with insulin production
a. Obesity leads to insulin resistance REASONING: Excess fat alters glucose metabolism, causing cells to become insulin resistant. Fat cells have no relationship to the function of the kidneys. Fat cells do not absorb insulin and therefore do not prevent the circulation of insulin to other cells. Clients with type 1 diabetes do not produce insulin. If lipids should accumulate in the pancreas of a healthy adult, they do not interfere with insulin production.
A client states, "I keep my insulin in the refrigerator because that is where my parents kept it." What reason should the nurse include when explaining that insulin should be stored at room temperature? a. Its potency and effectiveness are maximized. b. Absorption is enhanced and local irritation is decreased. c.. It is more convenient and drawing insulin into the syringe is facilitated. d. Adherence of insulin to the syringe and resistance upon injection are decreased.
b. Absorption is enhanced and local irritation is decreased. REASONING: Insulin can be stored at room temperature for up to 1 month but must be kept away from heat or sunlight. Inappropriate storage of insulin can decrease its stability and therefore decrease its therapeutic action. Insulin that is close to body temperature prevents vasoconstriction at the site and decreases irritation of tissues. Although it is more convenient, this is not a valid rationale; temperature of the solution does not increase the viscosity of insulin. Neither adherence of insulin to the syringe or decreased resistance upon injection occurs; the temperature of the solution does not increase the viscosity of insulin.
The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L. When monitoring the ECG tracing, the nurse expects to observe: a. Abnormal P waves and depressed T waves b. Peaked T waves and widened QRS complexes c.Abnormal Q waves and prolonged ST segments d. Peaked P waves and an increased number of T waves
b. Peaked T waves and widened QRS complexes REASONING: Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. The T wave is depressed in hypokalemia. Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The ST segment becomes depressed. The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change
A client is recuperating from a spinal cord injury at the T4 level and depends on a wheelchair for mobility. What should the nurse teach the client to prepare for use of a wheelchair? a. Leg lifts to prevent hip contractures b. Push-ups to strengthen arm muscles c. Balancing exercises to promote equilibrium d. Quadriceps-setting exercises to maintain muscle tone
b. Push-ups to strengthen arm muscles REASONING: Arm strength is necessary for transfers and activities of daily living and for the use of crutches or a wheelchair. Equilibrium is not a problem. The client does not have neurological control of hip contractures and maintaining muscle tone.
