1.
Which of the following will a nurse assess for hyperkalemia following unilateral adrenalectomy?
Correct Answer
A. Muscle weakness
Explanation
In patients with hyperkalemia, vital signs generally are normal. Nonspecific findings can include muscle weakness, fatigue, and depression.
2.
A patient with diabetes mellitus is experiencing symptoms of hypoglycemia. Which intervention should the nurse prioritize?
Correct Answer
A. Providing the patient with a snack or drink containing sugar.
Explanation
Immediate and frequent glucose monitoring is vital for any patient presenting with symptoms of unstable blood glucose, particularly with hypoglycemia.
3.
A client with hyperthyroidism presents with increased heart rate, weight loss, and heat intolerance. Which intervention is a priority for this client?
Correct Answer
B. Monitoring the client's heart rate and rhythm regularly.
Explanation
Monitoring the client's heart rate and rhythm regularly is a priority for a client with hyperthyroidism because increased heart rate is a common symptom of this condition. Hyperthyroidism can cause the heart to work harder, leading to potential complications such as arrhythmias or heart failure. Therefore, regular monitoring of the client's heart rate and rhythm is essential to detect any abnormalities and intervene promptly if necessary. Administering levothyroxine, assisting with relaxation techniques, and providing a high-calorie diet may also be important interventions, but they are not the priority in this case.
4.
A patient with Addison's disease is at risk for an adrenal crisis. Which assessment finding requires immediate nursing intervention?
Correct Answer
C. Hypotension and dizziness
Explanation
Hypotension and dizziness in a patient with Addison's disease indicate a potential adrenal crisis, which is a life-threatening condition. Addison's disease is characterized by a deficiency of cortisol and aldosterone, hormones that help regulate blood pressure. Hypotension and dizziness can be signs of low blood pressure, which can lead to shock if not promptly addressed. Immediate nursing intervention is necessary to stabilize the patient's blood pressure and prevent further complications.
5.
A client with pheochromocytoma is experiencing a hypertensive crisis. Which medication should the nurse anticipate administering?
Correct Answer
D. Beta-blockers
Explanation
Beta-blockers are given to clients with pheochromocytoma experiencing a hypertensive crisis because they block the effects of excess adrenaline (epinephrine) and noradrenaline (norepinephrine) in the body.
6.
What is the appropriate intervention for SIADH?
Correct Answer
C. Restricting fluids
Explanation
To reduce water retention in a client with the SIADH. the nurse should restrict fluids. Administering fluids by any route would further increase the client’s already heightened fluid load.
7.
A female client has a serum calcium level of 7.2 mg/dl. During the physical examination. What would the nurse expects to assess?
Correct Answer
A. Trousseau’s sign
Explanation
This client’s serum calcium level indicates hypocalcemia. an electrolyte imbalance that causes Trousseau’s sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans’ sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar’s sign (softening of the uterine isthmus) and Goodell’s sign (cervical softening) are probable signs of pregnancy.
8.
A patient with hyperparathyroidism is at risk for developing complications. Which instruction should the nurse provide to the client to minimize complications?
Correct Answer
A. Encourage pHysical activity to promote bone health
Explanation
Encouraging physical activity helps to promote bone health in patients with hyperparathyroidism. Regular exercise can help to strengthen bones and prevent bone loss, which is important for individuals with this condition. It also helps to improve overall health and reduce the risk of other complications associated with hyperparathyroidism.
9.
A patient with type 1 diabetes mellitus presents with fruity breath odor, rapid breathing, and confusion. Which condition should the nurse suspect?
Correct Answer
A. Diabetic ketoacidosis (DKA)
Explanation
The symptoms of fruity breath odor, rapid breathing, and confusion are indicative of diabetic ketoacidosis (DKA). DKA occurs when there is a severe lack of insulin in the body, leading to high blood sugar levels and the breakdown of fat for energy. This breakdown of fat produces ketones, which can be detected in the breath as a fruity odor. Rapid breathing, known as Kussmaul respirations, is the body's attempt to eliminate excess acids. Confusion can occur due to the metabolic imbalances caused by DKA. Hyperglycemic hyperosmolar state (HHS) is a different condition characterized by extremely high blood sugar levels, but it does not typically present with fruity breath odor or rapid breathing. Hypoglycemia is low blood sugar, which would not cause fruity breath odor or rapid breathing. Diabetic nephropathy is a complication of diabetes that affects the kidneys and would not present with these symptoms.
10.
A client with hypothyroidism is prescribed levothyroxine. When should the nurse instruct the client to take the medication?
Correct Answer
D. In the morning, on an empty stomach
Explanation
Levothyroxine is a synthetic form of thyroid hormone that is used to treat hypothyroidism. It is best absorbed on an empty stomach, so taking it in the morning before eating allows for optimal absorption. Taking it consistently at the same time every day helps maintain a steady level of the medication in the body. Taking it before bedtime may interfere with sleep, and taking it with a meal can decrease its absorption and increase the risk of gastrointestinal side effects. Therefore, the nurse should instruct the client to take levothyroxine in the morning, on an empty stomach.