Elevate Module 4
What is priority for the client experiencing hyperparathyroid crisis? 1. Support for airway and breathing. 2. Continuous cardiac monitoring for arrhythmias. 3. Provide safety precautions. 4. Prepare for emergency tracheostomy.
1 Rationale 1. Correct: Always remember ABC, if it is relevant, and it is with hyperparathyroid crisis. 2. Incorrect: Circulation is important. This priority comes after attention has been directed toward airway and breathing. What good would come of circulating deoxygenated blood, and how long can the heart muscle last without oxygen? Always remember ABC when prioritizing in emergency situations. 3. Incorrect: Muscle weakness, thus risk for falls is a concern, but airway takes priority! 4. Incorrect: Trach would be more likely with hypoparathyroidism. Remember, in hypoparathyroidism, the client would have rigid and tight muscles which would cause laryngospasms. Let's Talk There is the word "priority". So you have one shot to tell the NCLEX lady the most important thing to do here. So what is hyperparathyroid crisis? When you see parathryroid, you should think calcium. So hyperparathyroid crisis is way too much calcium. And calcium acts like what? A sedative. That means muscles tone will be decreased and there will be a decreased respiratory rate. Airway takes priority when it is applicable, and it is here.
What medication would the nurse anticipate for the treatment of hypothyroidism? 1. Levothyroxine 2. Methimazole 3. Potassium iodide 4. Propylthiouracil
1 Rationale 1. Correct: The client will receive levothyroxine, because what is levothyroxine? That's right it's the synthetic form of T4. 2. Incorrect: Methimazole is correct because it decreases the production of thyroid hormones. It is an antithyroid drug and it is used to "stun" the thyroid pre-operatively. It makes the thyroid "freak out" and stop producing hormones temporarily. 3. Incorrect: Iodine compounds like Lugol's solution® are incorrect because doses of iodine will do what? That's right, large doses will decrease thyroid hormone production for a few weeks. So we do not use an Iodine compound for Hypothyroidism. 4. Incorrect: Propylthiouracil stops the thyroid gland from making too much thyroid hormone. That is not a problem with hypothyroidism.
A client diagnosed with cancer has been losing weight. What should the nurse teach the client regarding methods for improving nutritional needs to maintain weight? 1. Add butter to foods 2. Spread peanut butter on toast 3. Add powdered creamer to milkshake 4. Use biscuits to make sandwiches 5. Eat Caesar salads once per day 6. Put honey on top of hot cereal
1, 2, 3, 4, 6 Rationale 1., 2., 3., 4., & 6. Correct: Butter and oil added to food will add calories. This client needs more calories and more protein. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, or crackers. Use croissants or biscuits to make sandwiches which provides more calories. Add powered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter. 5. Incorrect: Choose meat salads, such as chicken, ham, turkey, or tuna.
What signs and symptoms of ovarian cancer should a nurse include when educating women? 1. Menorrhagia 2. Loss of appetite 3. Urinary frequency 4. Decreasing abdominal girth 5. Pelvic pain 6. Change in bowel habits
1, 2, 3, 5, 6 Rationale 1., 2., 3., 5., 6. Correct: Signs and symptoms of ovarian cancer include irregular menses, increasing premenstrual tension, menorrhagia with breast tenderness, early menopause, abdominal discomfort, dyspepsia, Loss of appetite, pelvic pressure and urinary frequency. Indigestion, flatulence, and fullness after a light meal, and increasing abdominal girth are significant symptoms. Change in bowel habits such as constipation. 4. Incorrect: Abdominal girth will increase, not decrease.
A client has been prescribed levothyroxine sodium. What should the nurse teach the client about this medication? 1. Therapy will last a lifetime. 2. Notify the primary healthcare provider of chest discomfort. 3. Take medication with breakfast. 4. Do not take medication with iron supplements. 5. Improvement of symptoms will occur within days.
1, 2, 4 Rationale 1., 2., & 4. Correct: YES! Therapy is for a lifetime. The client should seek medical help immediately if the side effect of chest discomfort or pain occurs. It could be an MI. The client should not be administered within 4 hours of iron supplements. 3. Incorrect: It is preferable to take medication on an empty stomach, ½ — 1 hr before breakfast. Do not take with food. 5. Incorrect: It may take several weeks for symptoms to improve. Let's Talk So what is levothyroxine? It is a replacement for a hormone normally produced by the thyroid gland to regulate the body's energy and metabolism. It is given when the thyroid does not produce enough of this hormone on its own. Levothyroxine treats hypothyroidism and is also used to treat or prevent goiter, which can be caused by hormone imbalances, radiation treatment, surgery, or cancer. Levothyroxine works best if taken on an empty stomach, at least 30 minutes before breakfast. The client should follow dosing instructions and try to take the medicine at the same time each day. It may take several weeks before the body starts to respond to levothyroxine. The client should keep using this medicine even if feeling well. This medication may need to be taken for the rest of the client's life to replace the thyroid hormone the body cannot produce. Certain medicines can make levothyroxine less effective if taken at the same time. Iron, calcium and antacids decrease absorption of levothyroxine sodium. If using any of the following drugs, avoid taking them within 4 hours before or 4 hours after taking levothyroxine: calcium carbonate, cholestyramine, colestipol, ferrous sulfate iron supplement, sucralfate, sodium polystyrene sulfonate, antacids that contain aluminum or magnesium. The client should avoid the following food products, which can make the body absorb less levothyroxine: infant soy formula, cotton seed meal, walnuts, and high-fiber foods.
A client who has diabetes calls the nurse hot-line reporting shakiness, nervousness, and palpitations. Which questions would yield information that would help the nurse decide that this is a hypoglycemic episode? 1. What, and when, have you eaten today? 2. Do you feel sleepy? 3. Have you been extremely thirsty? 4. Can you check your current glucose level? 5. Does your skin feel sweaty? 6. Is your vision blurry?
1, 2, 4, 5, 6 Rationale 1., 2., 4., 5., & 6. Correct. This question will give the nurse information about how much time has elapsed since the last meal and will indicate the amount of protein and carbohydrates consumed at the last meal. Even a minor delay in meal times may result in hypoglycemia. As hypoglycemia worsens, level of consciousness declines. So asking if the client is sleepy is a good question. If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now. The skin gets cool and clammy (sweaty) with hypoglycemia. As the brain gets less glucose, the eyes are affected. 3. Incorrect. Polydipsia is a sign of hyperglycemia. Let's Talk A low blood sugar level triggers the release of epinephrine (adrenaline), the "fight-or-flight" hormone. Epinephrine is what can cause the symptoms of hypoglycemia such as thumping heart, sweating, tingling and anxiety.This question wants the nurse to verify that the client on the phone is having a hypoglycemic episode. So what questions could the nurse ask to verify this diagnosis? Option 1. Is it important to know if the client has eaten and what time? Yes. If the client has not eaten, would that lead to hypoglycemia? Yes. So this is true. Option 2. True. As hypoglycemia worsens, level of consciousness declines. Brain cells are affected and die as glucose levels decrease. So asking if the client is sleepy is a good question. Option 3. False. Polydipsia is a sign of hyperglycemia. Option 4. True. If the client has a glucose monitor, an accurate reading would give the nurse valuable information about how much food the client should consume now. Option 5. True. When the body is in any type of circulatory crisis, adrenaline prompts a decrease in the blood flow to peripheral areas of the body in order to redirect more blood to the vital organs. This causes the cool and clammy skin. One frequent cause of clammy skin includes hypoglycemia. Option 6. True. If the blood sugar level continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness.
Which risk factor(s) should the nurse include when planning to educate a group of women about breast cancer? 1. Combination hormone therapy 2. Drinking one glass of wine daily 3. Nulliparity 4. Menarche at age 10 5. Increasing age
1, 3, 4, 5 Rationale 1., 3., 4. & 5. Correct: Postmenopausal combination hormone therapy increases the risk for breast cancer. Estrogen-only hormone replacement therapy seems to lower breast cancer risk. Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure. Early menarche before age 12 is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle and the greater her lifetime exposure to estrogen. The majority of breast cancer are found in women age 50 or older. 2. Incorrect: Small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may in turn, increase the risk of breast cancer. Let's Talk The test taker must be aware of risk factors that cause breast cancer. Factors that are associated with an increased risk of breast cancer include: Being female, increasing age, a personal history of breast cancer, a family history of breast cancer, inherited genes, such as BRCA1 and BRCA2, that increase cancer risk, radiation exposure to chest as a child or young adult, obesity, menarche at a younger age (before 12), beginning menopause at an older age, having first child at an older age (after 35), having never been pregnant, postmenopausal hormone therapy, drinking alcohol.
A client diagnosed with hypothyroidism has been taking levothyroxine in increasing doses over the past week. Which findings, if present, would indicate to the nurse that the drug dosage is too high? 1. Irritability 2. Weight gain 3. Tachycardia 4. Tremors 5. Headache 6. Bradycardia
1, 3, 4, 5 Rationale 1., 3., 4., & 5. Correct: When a nurse administers levothyroxine, there is an expected therapeutic response of increase in energy, improved affect, improved gastric motility, weight loss, and less sensitivity to cold. If the levothyroxine dose is too high, the client may experience an tachycardia, dysrhythmias, tremors, and a headache. When the levothyroxine level is too high, the symptoms are the same as hyperthyroidism. 2. Incorrect: Weight gain is a symptom of the decrease level of the thyroid hormones, T3 and/or T4. This is a symptom of hypothyroidism. 6. Incorrect: Bradycardia is a symptom of hypothyroidism. This is a result of a decrease in the thyroid hormones, T3 and/or T4 is a s/s of hypothyroidism.
What should the nurse include in the teaching plan for a client receiving external beam radiation? 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. The machine will make clicking and whirring noises. 5. You can breath normally during radiation treatment. 6. You will not become radioactive.
1, 3, 4, 5, 6 Rationale 1., 3., 4., 5., & 6. Correct: Small ink marks or small tattoos will be placed on the skin to mark the treatment area. Do not remove the marks. The radiation therapist can see, hear, and talk to the client at all times during treatment. Relieve anxiety by letting client know he/she is not alone. The machine will indeed make clicking and whirring noises. Letting the client know this will also relieve anxiety. Client is not radioactive and will not radiate others. The client can safely be around other people, babies, and children. The client will need to stay very still so radiation goes to the exact same place each time, but can breathe as always and does not have to hold breath. 2. Incorrect: Do not put lotion, powder or deodorant near or on treatment area.
A nurse is assigned a client who is one day post thyroidectomy. While taking the blood pressure, the client's hand starts to tremble. What actions should the nurse take? 1. Pad the side rails 2. Monitor potassium level 3. Take blood pressure in opposite arm 4. Place trach set at bedside 5. Check for airway patency 6. Assess heart rhythm
1, 4, 5, 6 Rationale 1., 4., 5., & 6. Correct: During the thyroidectomy the parathyroid(s) could have been removed causing a decrease in the calcium level and could progress to a seizure and laryngospasms. Padding the side rails is a safety precaution for seizures. The nurse places a trach set at the bedside in case of laryngospasms. Check for airway patency as the esophagus is a smooth muscle. Think muscles with calcium and with hypocalcemia remember not enough sedative. The heart is a smooth muscle. It is important to check for arrhythmias. 2. Incorrect: I am worried about calcium with the parathyroid, not potassium. The NCLEX Lady thought you would see arrhythmia and say potassium, but calcium can cause heart problems as well. 3. Incorrect: This action is not needed. This would only provide you with the same response and delay treatment.
Which client instruction is important when the client is scheduled for a vanillylmandelic acid (VMA) test? 1. Desserts should not be eaten 72 hours prior to the test. 2. A 24 hour urine specimen requires starting with a full bladder. 3. Physical exercise should be continued throughout the test. 4. Avoid all commercially prepared foods for 24 hours prior to testing. 5. A preservative will be added to the collection container.
1, 5 Rationale 1., & 5. Correct: Sweets such as vanilla Coke®, chocolate pie, fudge brownies contain both caffeine and vanilla which would alter the VMA test. Most cakes and pastries contain vanilla, so clients are advised to avoid desserts prior to the test. Other specific foods to avoid are citrus fruits and bananas. This specimen requires a preservative. 2. Incorrect: The test requires a 24-hour urine specimen which is assessed for the presence of catecholamines (epinephrine and norepinephrine). The client must always discard the first voiding (starting with an empty bladder) and keep the last voided specimen within the 24-hour time frame. During the urine collection, the client must rest in a cool, quiet, non-stimulating environment so that stress hormones (epinephrine and norepinephrine) are not excreted in the urine. 3. Incorrect: Exercise causes a burst of catecholamines, as does smoking which would cause a false positive since the urine would be full of stress hormones from the adrenal medulla. 4. Incorrect: Any commercially prepared food can be consumed as long as the food does not contain any of the restricted foods such as vanilla and caffeine (CNS stimulant that would speed up the heart by increasing sympathetic and catecholamine production).
A 15 year old found unresponsive in the park is brought into the emergency department (ED). The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and attempts to call them have been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs for administration of normal saline. 3. Give Glucagon IM and wait for arrival of a parent to consent to further treatment. 4. Notify the pirmary healthcare provider.
2 Rationale 2. Correct: Consent for a minor is not needed in the event of an emergency. Begin treatment for Diabetic Ketoacidosis (DKA). 1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social worker does not give consent in this situation. 3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed. Emergency treatment can be provided without parental consent for a minor. 4. Incorrect: The primary healthcare provider cannot give consent or treatment in the ED. The ED physician and nurses can provide treatment in an emergency.
A client with a long-standing history of diabetes presents to the emergency department (ED) with a serum blood sugar of 400 mg/dL (22.19 mmol/L). What lab data for this client are consistent with diabetic ketoacidosis (DKA)? 1. Serum sodium 140 mEq/L (140 mmol/L) 2. Ketonuria 3. Serum potassium 5.5 mEq/L (5.5 mmol/L) 4. PaCO2 52 5. pH 7.35
2, 3 Rationale 2., & 3. Correct: Normally, no ketones are found in the urine. Ketonuria is associated with poorly controlled diabetes that results in hyperglycemia and breakdown of body fat and protein. Remember dilute makes numbers go down. The potassium will be elevated because insulin is needed to move potassium out of the blood and into the cell. 1. Incorrect: Sodium is essential for maintaining a stable blood pressure and fluid balance in the body. High blood sugar causes excessive urination with loss of body water and sodium. This can cause dehydration and low blood pressure. When the body needs to restore water to the bloodstream, it does so by pulling it from other tissues. This influx of water into the bloodstream may cause blood sodium to be further diluted. A low sodium level can cause symptoms of dizziness, fatigue, general weakness and, if severe, mental confusion or seizures. Insulin and intravenous fluids containing sodium chloride are used to treat the sodium deficit caused by DKA. This sodium level is normal (135-145). 4. Incorrect: The client will have an increased respiratory rate. So the PaCO2 will go down. This PaCO2 is high, so that correlates with hypoventilation. 5. Incorrect: This is a normal pH. With DKA, the client is in metabolic acidosis, so the pH will be low.
A nurse is planning discharge education for a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which instructions should the nurse include when teaching this client? 1. Increase fluid intake. 2. Report loss of energy. 3. Measure intake and output. 4. Perform mouth care once a day. 5. Report weight gain of 2 pounds (0.9 kg) over 24 hours.
2, 3, 5 Rationale 2., 3. & 5. Correct: The nurse should advise the client diagnosed SIADH to report loss of energy or fatigue. Loss of energy and fatigue should be reported immediately to the primary healthcare provider because these signs could indicate hyponatremia, which can lead to seizures or coma. The nurse should advise the client diagnosed with SIADH to measure intake and output. Intake and output should be monitored carefully to assess the amount of fluid restriction needed. Weight gain of 2 pounds (0.9 kg) or more should be reported to the primary healthcare provider because this is an indication of fluid retention and increases the client's risk for fluid volume excess. 1. Incorrect: The nurse should advise the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) to limit fluid intake. In SIADH, excessive amounts of water are reabsorbed by the kidneys, creating potentially disastrous dilutional hyponatremia. Water must be restricted to prevent water intoxication. 4. Incorrect: The nurse should teach the client to rinse the mouth frequently to keep mucous membranes moist during fluid restriction, not just once a day.
What is the priority nursing assessment for a client post-op thyroidectomy? 1. 5 mm dark red drainage 2. Temperature 99 F (37.2 C) 3. Trouseau's sign negative 4. Stridor
4 Rationale 4. Correct: Alright this is easy! Laryngeal/vocal cord edema is the most common cause of stridor within the first 24 hours after thyroidectomy. It is usually associated with difficulty breathing. Remember, a priority question on NCLEX is always concerned with what the nurse would do if they could only do one thing. 1. Incorrect: 5 mm of dark red drainage is normal after surgery. We worry about bright red blood. 2. Incorrect: A slight fever after surgery is expected. This is not the priority. 3. Incorrect: This is a normal finding. Nothing to worry about here.
What is the nursing priority for the client experiencing hyperparathyroidism? 1. Continuous cardiac monitoring. 2. Initiate fall precautions. 3. Administer IV normal saline. 4. Begin preparations for emergency parathyroidectomy.
1 Rationale 1. Correct: To much calcium equals sedation. Life threatening complications such as airway obstruction and cardiact arrest may occur from severely high levels of calcium. 2. Incorrect: Preventing injury is important because of bone density loss and risk of fractures. But it is not the priority. Done after maintaining airway and circulation. 3. Incorrect: IV normal saline in large volumes is done to promote calcium excretion, but it is not the priority over airway and circulation. 4. Incorrect: Surgery is indicated "when medically feasible". Cardiac monitoring is the priority at this time.
A client has been receiving 5-fluorouracil treatments for colon cancer and is admitted with weakness, fatigue, thrombocytopenia and low grade fever. Which actions would be appropriate for this client? 1. Have dedicated supplies in room 2. Place in private room 3. Provide high-calorie, high-protein diet 4. Limit visitors 5. Provide soft bristled toothbrush 6. Initiate airborne precautions
1, 2, 3, 4, 5 Rationale 1., 2., 3., 4., & 5. Correct. This client is at risk for infection and bleeding. Keeping dedicated supplies in room will decrease the risk of infection. Limiting visitors will decrease risk of infection. This client needs a private room because the client is immunocompromised. Unless contraindicated, the client would be prescribed a high-calorie, high-protein diet. Since the client is at risk for bleeding, a soft, rather than hard bristle toothbrush is needed. 6. Incorrect: Airborne precautions are not indicated for this client. Use airborne precautions for pathogens transmitted by the airborne route, such as tuberculosis.
What signs/symptoms would the nurse expect to find in a client admitted to the unit with a diagnosis of Addison's disease? 1. Salt cravings 2. Buffalo hump 3. Body hair loss 4. Acne 5. Hyperpigmentation 6. Hypotension
1, 3, 5, 6 Rationale 1., 3., 5., & 6. Correct: Addison's disease results in a decrease in glucocorticoids, mineralocorticoids, and sex hormones resulting in a body hair loss, darkening in skin color and hypotension. Salt cravings occur because the client's sodium level decreases. 2. Incorrect: Buffalo hump occurs with Cushing's. 4. Incorrect: Acne occurs with Cushing's. Let's Talk The adrenal glands are located on top of the kidneys. These glands produce many of the hormones that the body needs for normal functions. Addison's disease occurs when the adrenal cortex is damaged, and the adrenal glands do not produce enough of the steroid hormones cortisol and aldosterone. Cortisol regulates the body's reaction to stressful situations. Aldosterone helps with sodium and potassium regulation. The adrenal cortex also produces sex hormones. People who have Addison's disease may experience weakness in the muscles, fatigue and tiredness, hyperpigmentation, weight loss or decreased appetite, a decrease in heart rate/blood pressure, hypoglycemia, syncope, cravings for salt, gastrointestinal symptoms, body hair loss, irritability or depression. If Addison's disease goes untreated for too long, it can become an Addisonian crisis. An Addisonian crisis is a life-threatening medical emergency. Addisonian crisis can lead to shock and death. Option 1 is true. A deficiency of aldosterone in particular causes the body to excrete large amounts of sodium and retain potassium, leading to low levels of sodium and high levels of potassium in the blood. Option 2 is false. The Buffalo Hump is an accumulation of fat on the back of the neck and upper back. This condition can occur with over secretion of cortisone by the adrenal gland, a condition called Cushing's syndrome. Option 3 is true. Body hair loss occurs with Addison's. Option 4 is false. Cushing's occurs when the body is exposed to excessive levels of the steroid hormone cortisol. People with this condition are prone to acne because cortisol influences many other hormones, including the ones that trigger tiny glands in the skin to make oil. Option 5 is true. As Addison disease progresses, the adrenals put out less and less cortisol. The pituitary sees that decrease in cortisol levels and responds by making more adrenocorticotropic hormone (ACTH). ACTH is derived from a bigger precursor molecule called pro-opiomelanocortin (POMC). POMC is also a precursor for beta endorphin and melanocyte stimulating hormone (MSH)...so if you make more POMC (to make more ACTH), you'll make more beta endorphin and MSH. The MSH stimulates melanocytes, giving the skin a bronze color. Sometimes it's an all-over bronze, and sometimes it's more localized in the gums, or in areas subjected to increased pressure, like over the knuckles or in skin folds. Option 6 is true. With Addison's disease there is a decrease in aldosterone. What does aldosterone do? Helps you retain sodium and water. So, if you do not have enough aldosterone, you lose sodium and water. This will put you into a fluid volume deficit, or shock. What happens to the BP? Decreases.
A client with Cushing's disease is in a semi-private room. When considering room assignments, which client would be the safest choice to assign to this room? 1. Newly admitted client with Methicillin-resistant Staphylococcus aureus (MRSA). 2. Client with chronic kidney disease 3. Client who is post emergency cholecystectomy. 4. Client with full thickness burn of left leg.
2 Rationale 2. Correct: Chronic kidney disease is not infectious and would be the best roommate for the client with Cushing's disease who is immunosuppressed due to excessive secretion of glucocorticoids. 1. Incorrect: MESA is a contagious infectious disease and not the best choice to room with the client who has Cushing's disease. Remember, the client with cushing's is immunosuppressed. 3. Incorrect: A client post emergency cholecystectomy is prone to peritonitis or wound infection and not the best client choice. 4. Incorrect: Burns are always contaminated wounds, and the client has a decreased immune system, so a high probability for an infected burn would make this client a poor choice to occupy a room with the client who has Cushing's disease. This client is also immunosuppressed. Let's Talk Do you remember what is going on with the client who has Cushing's disease? To many glucocorticoids, mineralocorticoids, and sex hormones. This question wants you to select the safest roommate for this client. What is your number one safety concern here? That the client is immunocompromised because of too many glucocorticoids. So infection is a big concern. Who is the safest roommate for this immunocompromised person? Someone without an infection, right? That would be option 2, the client with chronic renal disease.
The nurse is caring for a client with bladder cancer who is 2 days post an ileal conduit. Assessment of the urinary output verifies that the urine has flecks of mucus and the hourly output has gone from 200 mL at 8:00 am to 140 mL at 10:00 am. What is the nurse's priority action? 1. Check for leakage from the stoma 2. Increase fluids to 2000 mL/24 hours 3. Monitor the site for signs of infection 4. Perform a bladder scan
2 Rationale 2. Correct: Increase fluids. Why? Well we have a drop in output, but it's still well within normal range and the client is two days post-procedure (not immediate post-op, when we would be most concerned about bleeding). So increase fluids to see if the output picks back up. Also, high fluid intake is helpful to flush the ileal conduit. 1. Incorrect: This is an appropriate nursing action, but is not the priority and does not address the decreased urine output. 3. Incorrect: This is an appropriate nursing action but not the priority. It does not address the decreased urinary output. 4. Incorrect: We would scan the bladder if we were worried about urinary retention. It's a little premature for that, but we could scan the bladder after increasing fluids. Remember this is a priority question.
What signs/symptoms would the nurse expect to find in a client admitted to the unit with a diagnosis of Cushing's disease? 1. Hyperpigmentation 2. Buffalo hump 3. Hirsutism 4. Acne 5. Moon face 6. Hypotension
2, 3, 4, 5 Rationale 2., 3., 4., & 5. Correct: Cushing's disease results in an increase in glucocorticoids, mineralocorticoids, and sex hormones resulting in a buffalo hump, hirsutism, acne, moon face, and hypertension. 1. Incorrect: Hyperpigmentation occurs when the body has too little cortisol, such as with Addison's disease. 6. Increase: Hypertension would occur with Cushing's Let's Talk Cushing disease (a form of Cushing syndrome) is a condition in which the pituitary gland releases too much adrenocorticotropic hormone (ACTH). Cushing disease is caused by a tumor or hyperplasia of the pituitary gland, located just below the base of the brain. With Cushing disease, the pituitary gland releases too much ACTH. ACTH stimulates production and release of cortisol. Too much ACTH causes the adrenal glands to make too much cortisol. Cortisol is normally released during stressful situations. It controls the body's use of carbohydrates, fats, and proteins. It also reduces the immune system's response to inflammation. Aldosterone helps with sodium and potassium regulation. The adrenal cortex also produces sex hormones. People who have Cushing's disease may experience upper body obesity and thin arms and legs, moon face, acne or skin infections, striae on the skin of the abdomen, thighs, upper arms, and breasts, thin skin with easy bruising, backache, bone pain and tenderness, buffalo hump, weakening bones, and weak muscles. Women may have excess hair growth on the face, neck, chest, abdomen, and thighs, and menstrual cycle that becomes irregular or stops. Men may have a low libido, and erection problems. Other symptoms may include mental changes, fatigue, frequent infections, headache, increased thirst and urination, hypertension, and diabetes. Option 1 is false. Hyperpigmentation occurs with Addison's disease. As Addison disease progresses, the adrenals put out less and less cortisol. The pituitary sees that decrease in cortisol levels and responds by making more adrenocorticotropic hormone (ACTH). ACTH is derived from a bigger precursor molecule called pro-opiomelanocortin (POMC). POMC is also a precursor for beta endorphin and melanocyte stimulating hormone (MSH)...so if you make more POMC (to make more ACTH), you'll make more beta endorphin and MSH. The MSH stimulates melanocytes, giving the skin a bronze color. Sometimes it's an all-over bronze, and sometimes it's more localized in the gums, or in areas subjected to increased pressure, like over the knuckles or in skin folds. Option 2 is true. The buffalo hump occurs with Cushing's. It is an accumulation of fat on the back of the neck and upper back. Due to over secretion of cortisone by the adrenal gland. Option 3 is true. Hirsutism is the abnormal growth of facial hair in a woman. Hirsutism can happen in Cushing's disease because the increased ACTH leads to a generalized increased production of hormones from the adrenal cortex and this includes the sex corticoids. Option 4 is true. Cushing syndrome occurs when the body is exposed to excessive levels of the steroid hormone cortisol. People with this condition are prone to acne because cortisol influences many other hormones, including the ones that trigger tiny glands in the skin to make oil. Option 5 is true. Moon face occurs when you have too many steroids, such as with Cushing's. Fatty deposits, due to the high release of cortisol, occur in the side of the face causing the round, moon-shaped face. Option 6 is false. With Cushing's disease there is an increase in aldosterone. What does aldosterone do? Helps you retain sodium and water. So, if you have too much aldosterone, you retain too much sodium and water. This will put you into a fluid volume excess. What happens to the BP? Increases.
Which client diagnosis would a prescription for an intravenous infusion of 1000 mL normal saline with 20 mEq (20 mmol) potassium chloride be appropriate? 1. Major burn injury 2. Kidney disease 3. Abdominal cramping with diarrhea 4. Diabetic Ketoacidosis (DKA) 5. Hypokalemia
3, 4, 5 Rationale 3., 4. & 5. Correct: Clients with abdominal cramping with diarrhea, diabetic ketoacidosis, and hypokalemia are safe to receive normal saline with potassium chloride. A primary electrolyte found in the lower GI tract is potassium. Therefore, diarrhea can result in excessive losses of potassium and associated hypokalemia can occur. When insulin is given to the client in DKA, it causes a transport of both glucose and potassium out of the blood and into the cell, resulting in hypokalemia. Finally, a client who has hypokalemia from other causes would need potassium replacement as well. 1. Incorrect: Tissue destruction from a major burn will cause release of potassium from the cell and into the blood. Thus, hyperkalemia occurs. An IV infusion with potassium will make the problem worse. 2. Incorrect: With kidney disease and the resulting diminished renal function, the client is at risk for sodium and potassium retention.
A nurse is reviewing serum laboratory data for four clients. Which client would require the most immediate assessment? Exhibit Client A: Lab Test Result: Thyroid-stimulating hormone (TSH) 11 mU/L (11µU/mL) Normal Ranges: 2 -10 mU/L (2-10 µU/mL) Client B: Lab Test Result: Free T4 (thyroxine) 0.8 ng/dL (10 pmol/L) Normal Ranges: 0.8 - 2.8 ng/dL (10-36 pmol/L) Client C Lab Test Result: Growth hormone 8 ng/mL (8 mcg/L) Normal Ranges: 0-6 ng/mL (0-6 mcg/L) Client D Lab Test Result: Glucose 40 mg/dL (2.2 mmol/L) Normal Ranges:70 - 110 mg/dL (3.9-6.2 mmol/L) 1. Client A 2. Client B 3. Client C 4. Client D
4 Rationale 4. Correct: The glucose level is low at 40. A low glucose is dangerous. Brain cells die! Seizure, coma, and death can occur if this is not treated. 1. Incorrect: An elevated TSH level occurs in hypothyroidism. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones which are essential for life. But this in not life-threatening. 2. Incorrect: The T4 level is low normal and should be monitored. The client might be headed for hypothyroidism. At present, this value does not indicate a life threatening problem. 3. Incorrect: An elevated growth hormone produces acromegaly with resulting bone and soft tissue deformities and enlarged viscera. But this is not life threatening.
The nurse is caring for a poorly controlled type 2 diabetic client. Lab results include a BUN of 22mg/dL (7.85 mmol/L) and a creatinine of 1.9 mg/dL (0.67 mmol/L). The nurse checks the client's blood sugar and it is 218mg/dL (12.09 mmol/L). Current medications include metformin and exenatide. What is the priority concern with this client taking metformin? 1. Inadequate blood glucose control 2. Concomitant administration of metformin and exenatide 3. Reports of headache 4. Renal function impairment
4 Rationale 4. Correct: This is the priority response. Why? Because metformin is eliminated primarily by the kidneys, and if the kidneys are not working properly, as evidenced by the elevated BUN and creatinine levels, administration of metformin can lead to toxicity and increased lactic acidosis risk. 1. Incorrect: Now there is a lot to know about metformin, and I'm a brand new nurse! The glucose is not where I want it to be, but is a blood sugar of 218 mg/dL going to kill me? No. 2. Incorrect: Exenatide and metformin are commonly prescribed together to control a client's glucose level, so this should not be a concern. 3. Incorrect: Headache is a side effect of metformin and the primary healthcare provider may be notified. However, this is not the priority.
A client, who is receiving an IV vesicant agent, reports pain at the intravenous site. What actions should the nurse take? Place in the appropriate order for these actions. The Correct Order 1. Stop administration of IV fluids. 2. Disconnect the IV tube from the cannula. 3. Administer a drug-specific antidote. 4. Notify the primary healthcare provider.
This is the Correct Order Rationale At the first sign of extravasation, the following steps are recommended: (1) stop administration of IV fluids immediately, (2) disconnect the IV tube from the cannula, (3) aspirate any residual drug from the cannula, (4) administer a drug-specific antidote, and (5) notify the physician
