MCA II Exam 3

Which type of hepatitis develops into a chronic form of the disease? select all that apply. a. hepatitis A b. hepatitis B c. hepatitis C d. hepatitis D e. hepatitis E

B, C, D Hepatitis B and C generally develop into chronic hepatitis. Hepatitis D is an incomplete virus that can become chronic and is dependent on the presence of hepatitis B to survive. Hepatitis A and E are acute, self-limiting infections that resolve over time and do not develop with chronic hepatitis.

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)? a. Increased thyroxine (T4) level b. Blood pressure 112/62 mm Hg c. Distant and difficult to hear heart sounds d. Elevated thyroid stimulating hormone level

a. Increased thyroxine (T4) level An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine.

while reviewing the client's laboratory reports, the nurse finds that there is an elevation in the client's growth hormone levels. which key physical changes would the nurse expect to find if acromegaly is suspected? select all that apply a. facial shape b. body weight c. chest shape d. lip thickness e. length of hands

A, C, D, E acromegaly may occur as a result of overproduction of growth hormone by the pituitary gland, which results in a few physical changes. the client with acromegaly would experience a barrel-shaped chest, enlarged facial features including bones and thickened lips, and enlarged hands and feet. clients who have hyperfunction of adrenocorticotropic hormone have weight gain.

Which nursing assessment of a 70-yr-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness

b. Apical pulse rate In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? a. Advise limiting alcohol intake to 1 drink daily. b. Schedule for liver cancer screening every 6 months. c. Initiate administration of the hepatitis C vaccine series. d. Monitor anti-hepatitis B surface antigen (anti-HBs) levels.

b. Schedule for liver cancer screening every 6 months. Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months. Patients with chronic hepatitis are advised to completely avoid alcohol. There is no hepatitis C vaccine. Because anti-HBs is present whenever there has been a past hepatitis B infection or vaccination, there is no need to regularly monitor for this antibody.

A client with a family history of goiter is experiencing changes in voice and breathing. Which diagnostic study does the nurse consider to be beneficial in confirming a diagnosis? a. thyroglobulin b. thyroid antibodies c. thyroxine (free T4), total d. thyroid-stimulating hormone (TSH)

b. thyroid antibodies Changes in voice and breathing can be seen in Hashimoto's thyroiditis if the thyroid gland enlarges rapidly and constricts the trachea and laryngeal nerves. Clients with a family history of goiter may have this condition. A thyroid antibody test is used diagnose Hashimoto's thyroiditis by differentiating thyroid dysfunction from thyroiditis.

The nurse determines that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient's a. weight has increased. b. urinary output is increased. c. peripheral edema is increased. d. urine specific gravity is increased.

b. urinary output is increased. Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.

which clinical indicator would the nurse expect to find when assessing a client with excess antidiuretic hormone? a. polyuria b. dehydration c. hyponatremia d. hyperglycemia

c. hyponatremia antidiuretic hormone (ADH) causes increased resorption of water by renal tubules, which dilutes sodium levels, causing hyponatremia. ADH will decrease urine volume. ADH causes fluid retention. ADH does not alter glucose metabolism.

A nurse is providing postoperative care for a client who has begun taking levothyroxine after undergoing a thyroidectomy. Which findings in the client may indicate potential thyrotoxic crisis? a. Elevated serum calcium b. Sudden drop in pulse rate c. Hypothermia and dry skin d. Rapid heartbeat and tremors

d. Rapid heartbeat and tremors Thyrotoxic crisis (thyroid storm) refers to a sudden and excessive release of thyroid hormones, which causes pyrexia, tachycardia, and exaggerated symptoms of thyrotoxicosis; surgery, infection, and ablation therapy can precipitate this life-threatening condition. Hypercalcemia is not related to thyrotoxic crisis; hypocalcemia results from accidental removal of the parathyroid glands. Tachycardia is an increased, not decreased, heart rate, which occurs with thyrotoxic crisis because of the sudden release of thyroid hormones; thyroid hormones increase the basal metabolic rate. Fever, not hypothermia, and diaphoresis, not dry skin, occur with thyrotoxic crisis because of the sudden release of thyroid hormones, which increase the basal metabolic rate.h

A young adult contracts hepatitis from contaminated food. During the acute (icteric) phase ofthe patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appearsduring the acute phase of hepatitis A. The patient would not have antigen for hepatitis B orantibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls that the procedure is performed for what reasons? (Select all that apply.) a. extract peritoneal fluid b. improve respiratory status c. decrease intrapleural fluid d. increase intra-abdominal tension e. obtain peritoneal fluid for culture

A, B, E when a client has ascites, a peritoneal tap (paracentesis) may be prescribed to remove fluid for diagnostic purposes and for relief of discomfort. the removal of intra-abdominal fluid relieves pressure against the diaphragm, which will improve the client's respiratory status. a culture of peritoneal fluid may provide information about the cause of the ascites. closed-chest drainage, not paracentesis, removes fluid from the pleural space. paracentesis is done to decrease, not increase, intra-abdominal pressure.

The nurse is admitting a client with severe myxedema coma. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. a. Administer intravenous (IV) levothyroxine. b. Avoid use of corticosteroids. c. Give IV normal saline. d. Wait for laboratory results before treating. e. Monitor blood pressure every 4 hours.

A, C myxedema coma is a major complication of poorly treated hypothyroidism. interventions include administering IV levothyroxine. this promotes the return of normal thyroid hormone levels. IV normal saline corrects dehydration. corticosteriods are administered as part of the treatment. levothyroxine is initiated before obtaining laboratory results because waiting can cause death. the blood pressure should be monitored hourly.

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply. a. Vomiting b. Hyperthermia c. Bradycardia d. increased weight e. Decreased serum sodium f. Decreased level of consciousness

A, D, E, F Water retention and decreased urinary output occur because of excess secretion of antidiuretic hormone (ADH). Early manifestations are related to water retention and may include gastrointestinal (GI) disturbances, such as loss of appetite, nausea, and vomiting. Weight gain occurs because of the water retention. Serum sodium levels are decreased because of fluid retention and sodium loss. Central nervous system changes include headaches, lethargy, and decreased level of consciousness, progressing to coma and seizures. Hypothermia also occurs because of central nervous system disturbance. The pulse is full and bounding because of the increased fluid volume.

While assessing a postpartum client who is suspected of having a thyroid disorder, the nurse suspects that the client has autoimmune thyroiditis. Which diagnostic studies are most suitable for confirming the diagnosis? a. Radioactive iodine uptake b. computed tomography scan c. magnetic resonance imaging d. thyroid-stimulating hormone

a. Radioactive iodine uptake the postpartum client may have silent, painless thyroiditis. radioactive iodine uptake is suppressed in silent thyroiditis, so this test would be beneficial in diagnosing the thyroiditis. a computed tomography scan is used to detect thyroid nodules. magnetic resonance imaging is also used in evaluating thyroid nodules. a blood test for thyroid-stimulating hormone is used to evaluate thyroid function.

A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Administer the HCV vaccine and immune globulin. c. Teach the patient about ribavirin (Rebetol) treatment. d. Explain that the infection will resolve over a few months.

a. Schedule the patient for HCV genotype testing. Genotyping of HCV has an important role in managing treatment and is done before drugtherapy is initiated. Because most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection.

The nurse administering a-interferon and ribavirin (Rebetol) to a patient with chronichepatitis C will plan to monitor for a. leukopenia. b. hypokalemia. c. polycythemia. d. hypoglycemia.

a. leukopenia. Therapy with ribavirin and -interferon may cause leukopenia. The other problems are not associated with this drug therapy.

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy hasbeen effective when the patient makes which statement a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will need to maintain a low-fat diet for life because I no longer have agallbladder."

b. "I can remove the bandages on my incisions tomorrow and take a shower." After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.

Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas.

b. Elevate the head of the patient's bed to reduce periorbital fluid. The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. Restrict the patient to bed rest. b. Encourage 4000 mL of fluids daily. c. Institute routine seizure precautions. d. Assess for positive Chvostek's sign.

b. Encourage 4000 mL of fluids daily. The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.

A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action will provide the patient with rapid relief from the symptoms? a. Administer the prescribed muscle relaxant. b. Have the patient rebreathe from a paper bag. c. Start the PRN O2 at 2 L/min per cannula. d. Stretch the muscles with passive range of motion.

b. Have the patient rebreathe from a paper bag. The patient's symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH. Applying as-needed O2 or range of motion will have no impact on the ionized calcium level. Calcium supplements will be given to normalize calcium levels quickly, but oral supplements will take time to be absorbed.

A 37-yr-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Difficult to awaken. b. Increasing neck swelling. c. Reports 7/10 incisional pain. d. Cardiac rate 112 beats/minute.

b. Increasing neck swelling. The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

Which information will the nurse include when teaching a 50-yr-old male patient about somatropin (Genotropin)? a.The medication will be needed for 3 to 6 months. b. Inject the medication subcutaneously every day. c. Blood glucose levels may decrease when taking the medication. d. Stop taking the medication if swelling of the hands or feet occurs.

b. Inject the medication subcutaneously every day. Somatropin is injected subcutaneously on a daily basis, preferably in the evening. The patient will need to continue on somatropin for life. If swelling or other common adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels.

Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify source of hepatitis exposure.

b. Maintain adequate nutrition. The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.

b. Measure urine volume every hour. After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? a. Patient with Hashimoto's thyroiditis and a heart rate of 102 b. Patient with tetany who has a new order for IV calcium chloride c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL d. Patient with Addison's disease who takes hydrocortisone twice daily

b. Patient with tetany who has a new order for IV calcium chloride Emergency treatment of tetany requires IV administration of calcium; electrocardiographic monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration. The information about the other patients indicates that they are more stable than the patient with tetany.

A 36-yr-old female patient is receiving treatment for chronic hepatitis C with pegylatedinterferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which findingis important to communicate to the health care provider to suggest a change in therapy? a. Weight loss of 2 lb (1 kg) b. Positive urine pregnancy test c. Hemoglobin level of 10.4 g/dL d. Complaints of nausea and anorexia

b. Positive urine pregnancy test Because ribavirin is teratogenic, the medication will need to be discontinued immediately. Anemia, weight loss, and nausea are common adverse effects of the prescribed regimen and may require actions such as patient teaching, but they would not require immediate cessation of the therapy.

Which information given by a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 20 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.

b. The patient used IV drugs about 20 years ago. Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992 (when an antibody test for hepatitis C became available) do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

b. ammonia levels. The protein in the blood in the gastrointestinal tract will be absorbed and may result in anincrease in the ammonia level because the liver cannot metabolize protein very well. Theprothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

The nurse is assessing a male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include: a. high blood pressure. b. decreased facial hair. c. elevated blood glucose. d. tachycardia and palpitations.

b. decreased facial hair. Changes in male secondary sex characteristics such as decreased facial hair, testicular atrophy, diminished spermatogenesis, loss of libido, impotence, and decreased muscle mass are associated with decreases in follicle stimulating hormone (FSH) and luteinizing hormone (LH). Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in adrenocorticotropic hormone (ACTH) and cortisol. Bradycardia is likely due to the decrease in thyroid-stimulating hormone (TSH) and thyroid hormones associated with panhypopituitarism.

A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client? a. thyroxine (T4) and x-ray films b. thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3) c. thyroglobulin level anad PO2 d. protein-bound iodine and sequential multichannel autoanalyzer (SMA)

b. thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3) a decreased TSH assay together with an elevated T3 level may indicate hyperthyroidism. x-ray films will not indicate thyroid disease, and elevation of T4 level might indicate hyperthyroidism. However, this may be a false reading because of the presence of thyroid-binding globulin (TBG) and is inadequate for diagnosis when used alone. PO2 is not specific to thyroid disease, and the thyroglobulin level is most useful to monitor for recurrence of thyroid carcinoma or response to therapy. the results with the SMA are not specific to thyroid disease; the protein-bound iodine test is not definitive because it is influenced by the intake of exogenous iodine.

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to: a. cough and deep breathe every 2 hours postoperatively. b. remain on bed rest for the first 48 hours after the surgery. c. avoid brushing teeth for at least 10 days after the surgery. d. be positioned flat with sandbags at the head postoperatively.

c. avoid brushing teeth for at least 10 days after the surgery. To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.

The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to: a. protect the patient's skin. b. monitor for signs of infection. c. balance fluids and electrolytes. d. prevent emotional disturbances.

c. balance fluids and electrolytes. After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.

which situation in a client with hyperthyroidism may precipitate thyroid crisis (thyroid storm)? a. increased iodine in the blood b. removal of the parathyroid glands c. high levels of the hormone triiodothyronine d. rebound increase in metabolism after anesthesia

c. high levels of the hormone triiodothyronine thyroid trauma, thyroid surgery, or physiological stress in a client with hyperthyrodism may lead to a release of abnormally high levels of thyroid hormones. high levels of the hormone triiodothyronine (T3) intensify all the signs and symptoms of hyperthyroidism (thyroid storm or crisis), such as increased temperature, pulse, and respirations, restlessness, vomiting, and often death. iodine binds with thyroxine, thus decreasing the potential for crisis. tetany, not thyroid crisis, occurs from surgical excision of the parathyroid glands. anesthesia will depress metabolism, not increase it.

A client with cirrhosis of the liver has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. What should the nurse instruct the client to do considering the client's condition? a. Avoid foods high in phytonadione b. Check the pulse several times a day. c. Drink a glass of milk when taking aspirin. d. Report signs of bleeding no matter how slight.

d. Report signs of bleeding no matter how slight. One of the many functions of the liver is the manufacture of clotting factors; there is interference in this process with cirrhosis of the liver, resulting in bleeding tendencies. The storage of fat-soluble vitamins (A, D, E, and K), water-soluble vitamins (B1, B2, folic acid, and cobalamin), and minerals (including iron) is compromised in cirrhosis; therefore, these nutrients, including phytonadione, should not be limited. Should the client bleed, the pulse rate may be increased, but it is not necessary for the client to check the pulse rate several times daily. A client whose prothrombin time is prolonged and platelet count is low should not be taking aspirin, even with milk.

Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Draw blood for hepatitis serology testing. c. Discuss the need to increase caloric intake. d. Review the patient's current medication list.

d. Review the patient's current medication list. Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? a. "Do you have a history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Have you used corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"

b. "Do you use any over-the-counter drugs?" The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

The nurse is assessing a client with a suspected thyroid disorder. Which= diagnostic studies will be most appropriate to confirm that the thyroid disorder is autoimmune in origin? Select all that apply. a. Free thyroxine b. Thyroglobulin antibody c. Thyroid peroxidase antibody d. Thyroid-stimulating antibody e. Thyroid-stimulating hormone

B, C, D Thyroglobulin, thyroid peroxidase, and thyroid-stimulating antibodies are assessed in a thyroid antibody test. This test helps to differentiate other forms of thyroiditis from autoimmune thyroid disease. An active component of total T4 is measured by free thyroxine but cannot differentiate the origin. Thyroid-stimulating hormone levels are used to evaluate a thyroid dysfunction but cannot differentiate the origin.

which clinical findings correspond with the secretion of antidiuretic hormone (ADH)? select all that apply. a. edema b. polyuria c. bradycardia d. muscle cramps e. hyponatremia

D, E muscle cramps occur when sodium level is less than 124 mEq/L and are caused by osmotic fluid shift. ADH causes water retention, which dilutes serum electrolytes such as sodium, with a resultant hyponatremia. edema is not usually seen in syndrome of inappropriate ADH (SIADH) because water retention is not extracellular.. a decreased urine output occurs with SIADH because ADH causes reabsorption of fluid in the kidney glomeruli. the increased fluid volume associated with SIADH results in tachycardia, tachypnea and crackles.

The nurse would monitor a client for which manifestation indicating a thyroid storm? select all that apply. a. Increased heart rate b. Increased temperature c. Decreased respirations d. Increased pulse deficit e. Decreased blood pressure

A, B thyroid storm is severe hyperthyroidism; excessive amounts of thyroxine increase the metabolic rate, thereby causing an increased heart rate (tachycardia). Because of the increased metabolic rate associated with thyroid storm, the respiratory rate increases (tachypnea) to meet the body's oxygen needs. pulse deficit, the difference between apical and peripheral pulse rates, is not indicative of thyroid storm. the blood pressure will increase to meet the oxygen demand caused by the increased metabolic rate during thyroid storm.

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

c. Amylase Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease? a. Estrogens b. Androgens c. Glucocorticoids d. aldosterone

d. aldosterone aldosterone can be impaired in its production because pf Addison disease, although Addison disease itself is caused by a cortisol deficiency. Aldosterone causes the kidneys to retain sodium ions. Increased sodium promotes water retention, which elevates blood pressure. the absence of aldosterone causes hypotension. the major effect of cortisol is on glucose metabolism and not on sodium and water concentrations, so the absence of this hormone will not cause significant hypotension. estrogen and androgens are sex hormones and do not affect blood pressure.

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

d. Albumin level The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.

Which questions would the nurse ask when assessing a client diagnosed with acromegaly? select all that apply. a. "have you noticed any changes to your vision?" b. "have you ever been told that you snore loudly?" c. "have you had any changes in your menstrual cycle?" d. "have you noticed any chances to your bowel movements?" e. "have you noted you consume excess amount of cruciferous vegetables?"

A, B, D It is reasonable to ask a client with acromegaly if he or she has experienced changes in his or her vision, because pressure on the optic nerve from a pituitary adenoma can occur. some clients with acromegaly will develop sleep apnea, secondary to upper airway narrowing and obstruction from increased amounts of pharyngeal soft tissues. clients with acromegaly are at an increased risk of colorectal cancer. it is not necessary to ask the client with acromegaly about her menstrual cycle; acromegaly is the overgrowth of soft tissue and bone in the hands, feet, and face, and does not affect the reproductive organs as some other excesses of tropic hormones do. intake of cruciferous vegetables will not affect acromegaly; the goitrogens in these vegetables contain thyroid-inhibiting substance and can lead to goiter if eaten in excessive amounts.

The nurse determines that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient makes which statement? a. "I need to shop for foods low in sodium and avoid adding salt to food." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I should eat foods high in potassium because diuretics cause potassium loss."

a. "I need to shop for foods low in sodium and avoid adding salt to food." Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels

a. Increasing serum sodium levels Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

a. The patient is alert and oriented. The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? a. "How much milk do you drink?" b. "What medications are you taking?" c. "Are your immunizations up to date?" d. "Have you had any recent neck injuries?"

b. "What medications are you taking?" Medications that contain thyroid- inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter.

which action is the function of antidiuretic hormone (ADH)? a. reduces blood volume b. decreases water loss in urine c. increases urine output d. initiates the thirst mechanism

b. decreases water loss in urine ADH is released by the posterior pituitary gland. it is released mainly in response to either a decrease in blood volume or an increased concentration of sodium or other substances in the plasma. ADH acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume; decreased ability of the kidneys to reabsorb water, resulting in increased urine output; and an increase in the thirst mechanism.

A nurse is caring for a client with a diagnosis of Cushing syndrome. What is the most common cause of Cushing syndrome that the nurse should consider before assessing this client for physiological responses? a. pituitary hypoplasia b. hyperplasia of the adrenal cortex c. deprivation of adrenocortical hormones d. insufficient adrenocorticotrophic hormone (ACTH) production

b. hyperplasia of the adrenal cortex hyperplasia of the adrenal cortex leads to increased secretion of cortical hormones, which causes signs of Cushing syndrome. pituitary hypoplasia is a malfunction of the pituitary that will result in Simmonds disease (panhypopituitarism), which has clinical manifestations similar to those for Addison disease. Cushing syndrome results from excessive cortical hormones. ACTH stimulates production of adrenal hormones. Inadequate ACTH will result in Addisonian signs and symptoms

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.

c. Administer prescribed opioids to relieve pain as needed. Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to teaching, or manage anxiety or depression.

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.

c. Assess the patient's respiratory effort. Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure and heart rate. d. Place the patient in the supine position.

c. Check blood pressure and heart rate. The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter are also appropriate. However, the vital signs may indicate the need for more urgent actions. Because aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in a supine position.

Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Encourage fluids to 2 to 3 L/day. b. Monitor for increasing peripheral edema. c. Offer the patient hard candies to suck on. d. Keep head of bed elevated to 30 degrees.

c. Offer the patient hard candies to suck on. Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.

A patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration? a. Ribavirin (Rebetol, Copegus) 600 mg PO bid b. Diphenhydramine 25 mg PO every 4 hours PRN itching c. Pegylated a-interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily d. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

c. Pegylated a-interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily Pegylated a-interferon is administered subcutaneously, not orally. The medications are all appropriate for a patient with chronic hepatitis C infection.

A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator to the nurse that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.

c. Stools test negative for occult blood. Because the purpose of -blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

A 62-yr-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient a. about radioactive precautions to take with all body secretions. b. that symptoms of hyperthyroidism should be relieved in about a week. c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. d. to discontinue the antithyroid medications taken before the radioactive therapy.

c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? a. Withhold both drugs. b. Administer both drugs c. Administer the furosemide. d. Administer the spironolactone.

d. Administer the spironolactone. Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

d. Place the patient on a pressure-relief mattress. The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

Which prescribed medication should the nurse expect will have rapid effects on a patientadmitted to the emergency department in thyroid storm? a. Iodine b. Methimazole c. Propylthiouracil d. Propranolol (Inderal)

d. Propranolol (Inderal) β-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)? a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about a-interferon therapy. d. Give hepatitis B immune globulin. e. Teach about choices for oral antiviral therapy.

A, B, D The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

b. Administer IV calcium gluconate. The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.

The nurse will plan to teach the patient diagnosed with acute hepatitis B about a. administering a-interferon b. side effects of nucleotide analogs. c. measures for improving the appetite. d. ways to increase activity and exercise.

c. measures for improving the appetite. Maintaining adequate nutritional intake is important for regeneration of hepatocytes Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.

a. maintaining normal respiratory function. Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

the nurse is caring for a client who is experiencing an underproduction of thyroxine (T4). with what diagnosis is this associated? a. myxedema b. acromegaly c. Graves disease d. Cushing disease

a. myxedema myxedema is the severest form of hypothyroidism. decreased thyroid gland activity means reduced production of thyroid hormones. acromegaly results from excess growth hormone in adults once the epiphyses are closed. graves disease results from an excess, not a deficiency, of thyroid hormones. cushing disease results from excess glucocorticoids.

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. A 31-yr-old female patient with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-yr-old male patient who has Addison's disease and is due for a prescribed dose of hydrocortisone (Solu-Cortef). d. A 22-yr-old male patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

b. A 70-yr-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

A patient is admitted with diabetes insipidus. Which action will be appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Titrate the infusion of 5% dextrose in water. b. Administer prescribed subcutaneous DDAVP. c. Assess the patient's overall hydration status every 8 hours. d. Teach the patient how to use desmopressin (DDAVP) nasal spray.

b. Administer prescribed subcutaneous DDAVP. Administration of medications is included in LPN/LVN education and scope of practice. Assessments, patient teaching, and titrating fluid infusions are more complex skills and should be done by the RN.

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.

b. anti-HBs. The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

Which assessment finding for a 33-yr-old female patient admitted with Graves' disease requires the most rapid intervention by the nurse? a. Heart rate 136 beats/min b. Severe bilateral exophthalmos c. Temperature 103.8° F (40.4° C) d. Blood pressure 166/100 mm Hg

c. Temperature 103.8° F (40.4° C) The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life threatening complications.

Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.

c. The medication will prevent irritation of the enlarged veins. Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purposes for H2-receptor blockade in this patient.

A client with esophageal varices has severe hematemesis, and a Sengstaken-Blakemore tube is inserted. What design and purpose does the tube have? a. single-lumen; for gastric lavage b. double-lumen; for intestinal decompression c. triple-lumen; for esophageal compression d. multi-lumen; for gastric and intestinal decompression

c. Triple-lumen; for esophageal compression the Sengstaken-Blakemore is a triple-lumen tube; one lumen inflates the esophageal balloon that compresses the esophagus, the second inflates the gastric balloon, and the third is attached to suction to decompress the stomach. The Sengstaken-Blakemore is not a single-lumen tube. The Sengstaken-Blakemore is not a double-lumen tube; the stomach, not the intestine, is decompressed. The intestine is not decompressed with a Sengstaken-Blakemore tube.

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

d. Abdominal pain is decreased. NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider? a. Changes in visual field b. Milk leaking from breasts c. Blood glucose 150 mg/dL d. Nausea and projectile vomiting

d. Nausea and projectile vomiting Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment. Changes in the visual field, elevated blood glucose, and galactorrhea are common with pituitary adenoma, but these do not require rapid action to prevent life-threatening complications.