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A Client is admitted to the hospital with severe Hypoparathyroidism. The nurse should do which of the following activities to promote client safety |
Institute seizure precautions- Rationale: Hypoparathyroidism results from insufficient parathyroid hormone, leading to low serum calcium levels. Hypocalcemia can cause tetany, which, if untreated, can lead to seizures. The nurse should institute seizure precautions to maintain a safe environment. The other options do nothing to help this health problem or promote a safe environment for this client. |
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A client is seen in the health care clinic, and a diagnosis of hypothyroidism is suspected. Which finding does the nurse expect to note in the client? |
Bradycardia- Rationale: Hypothyroidism is a condition characterized by decreased activity of the thyroid gland. Clinical manifestations associated with hypothyroidism include bradycardia; obesity; dry, sparse hair; flaky, dry, inelastic skin; and a lowered basal body temperature. The client’s ability to sweat also diminishes. Constipation and fecal impaction occur, and the client has an increased susceptibility to infection. The blood pressure may be normal or slightly elevated, and the temperature is normal to subnormal. Options 2, 3, and 4 are findings noted in hyperthyroidism. |
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A nurse is monitoring a client with hypothyroidism for neurological manifestations. Which of the following does the nurse expect to note in the client? |
Slow, deliberate speech Rationale: Hypothyroidism is a condition characterized by decreased activity of the thyroid gland. In hypothyroidism the client’s neurological manifestations include decreased deep tendon reflexes, muscle sluggishness, fatigue, slow and deliberate speech, apathy, depression, impaired short-term memory, and lethargy. Options of Fine Tremors, Restlessness, and Increased deep tendon reflexes are signs of hyperthyroidism. |
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A nurse is caring for a client with a diagnosis of thyroid crisis (thyroid storm). Which of the following should the nurse included in the plan of care for this client |
Use of a hypothermic Blanket Rational: Thyroid crisis is a potentially fatal acute episode of thyroid overactivity characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. Because thyroid storm is an emergency, it requires immediate interventions for control. The high fever is treated with hypothermic blankets, and dehydration is reversed with intravenous fluids. Hypothyroidism a nurse shoudl restrict fluid intake, Administration of levothyroxine (Snythroid), and Administration of enemas and stool softeners. |
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A nurse is assisting to prepare a plan of care for a client with hyperthyroidism and is instructed the client regarding dietary measures. Which of the following foods are included in the plan of care |
High calories Rationale: Hyperthyroidism is a condition characterized by hyperactivity of the thyroid gland. The client with hyperthyroidism is usually extremely hungry because of increased metabolism. The client should be instructed to consume a high-calorie diet with six full meals a day. The client should be instructed to eat foods that are nutritious and contain ample amounts of protein, carbohydrates, fats, and minerals. Clients should be discouraged from eating foods that increase peristalsis and thus result in diarrhea, such as highly seasoned, bulky, and fibrous foods. |
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The nurse is caring for a client after thyroidectomy and is monitoring for complications. Which of the following, if noted in the client, indicates a need for physician notification? |
Numbness and Tingling around the mouth. Rationale: Thyroidectomy is the surgical removal of the thyroid gland. Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or traumatized during surgery. The physician should be called immediately if the client develops numbness and tingling around the mouth or in the fingertips or toes, muscle spasms, or twitching. A hoarse or weak voice may occur temporarily if there has been unilateral injury to the laryngeal nerve during surgery. Pain is expected in the postoperative period. Calcium gluconate ampules should be available at the bedside, and the client should have a patent intravenous line in the event that hypocalcemic tetany occurs. |
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A nurse is providing dietary instructions to a client with a diagnosis of hyperparathyroidism. Which statement by the client indicates a need for further instructions? |
I should consume foods high in Vitamin Rationale: Hyperparathyroidism is an abnormal endocrine condition characterized by hyperactivity of any of the four parathyroid glands with excessive secretion of parathyroid hormone. The client with hyperparathyroidism should consume at least 3000 mL of fluid per day. Dehydration is dangerous because it increases the serum calcium levels and promotes the formation of renal stones. Cranberry and prune juices help make the urine more acidic. A high urinary acidity helps prevent renal stone formation because calcium is more soluble in an acidic than in an alkaline urine. Clients should maintain a low-calcium, low-vitamin D diet. High-fiber foods are important to prevent constipation and fecal impaction resulting from the hypercalcemia that occurs with this disorder. |
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A nurse is assisting in monitoring a client for signs of hypocalcemia. Which of the following should the nurse note on data collection if hypocalcemia is present |
Positive Trousseau’s Sign Rationale: Hypocalcemia is a deficiency of calcium in the serum. Data collection findings from the client who is hypocalcemic include a positive Chvostek’s sign and Trousseau’s sign, hyperactive deep tendon reflexes, circumoral paresthesia, and numbness and tingling of the fingers. A positive Homans’ sign is noted in thrombophlebitis. |
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A nurse is monitoring a client with hypoparathyroidism for signs of hypocalcemia. The nurse wraps a blood pressure (BP) cuff around the clients upper arm, fills the cuff, and monitors for spasms of the wrist and the hand. The nurse document the findings, kowning that this technique checks for the presence of which of the following? |
Trousseau’s Sign Rationale: Hypocalcemia is a deficiency of calcium in the serum. Trousseau’s sign occurs when spasms of the wrist and hand occur after compression of the upper arm by a BP cuff. Homans’ sign is the presence of pain in the calf area when the foot is dorsiflexed. Chvostek’s sign is present when spasms of the facial muscles occur after a tap over a facial nerve, signifying facial hyperirritability. The Allen’s test indicates adequate circulation to the hand before arterial blood gases are obtained. |
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Homan’s Sign |
In medicine, Homans’ sign was used as a sign of deep vein thrombosis (DVT). A positive sign is present when there is pain in the calf on dorsiflexion of the patient’s foot at the ankle while the knee is fully extended. |
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Chvostek’s Sign |
The Chvostek sign is one of the signs of tetany seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia (i.e. from hypoparathyroidism, pseudohypoparathyroidism, hypovitaminosis D) with resultant hyperexcitability of nerves. Though classically described in hypocalcemia, this sign may also be encountered in respiratory alkalosis, such as that seen in hyperventilation, which actually causes decreased serum Ca2+ with a normal calcium level due to a shift of Ca2+ from the blood to albumin which has become more negative in the alkalotic state. |
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Trousseau’s Sign |
Trousseau sign of latent tetany is a medical sign observed in patients with low calcium.[1] This sign may become positive before other gross manifestations of hypocalcemia such as hyperreflexia and tetany, as such it is generally believed to be more sensitive (94%) than the Chvostek sign (29%) for hypocalcemia.[2][3] To elicit the sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient’s hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct. The sign is also known as main d’accoucheur |
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Allen’s test |
In medicine, Allen’s test, also Allen test, 1) The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. 2) Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3) Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails). 4) Ulnar pressure is released and the colour should return in 7 seconds. Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial If color does not return or returns after 7-10 seconds, the test is considered positive and the ulnar artery supply to the hand is not sufficient. The radial artery therefore cannot be safely pricked/cannulated. |
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A client is diagnosed with hyperparathyroidism. The nurse plans to tell the client to limit which of the following foods in the diet? |
Yogurt Rationale: The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods. |
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A nurse is planning to reinforce teaching to a client with diabetes mellitus with hypertension about "sick day management". Which carbohydrate-containing beverage should the nurse avoid putting on a list of beverages for use when the client cannot tolerate solid food orally? |
Tomato Juice Rationale: Diabetic clients should take in approximately 15 g of carbohydrate every 1 to 2 hours when unable to tolerate food because of illness. The beverages listed in options 1, 2, and 3 provide approximately 13 to 15 g of carbohydrate in a ½-cup serving. Tomato juice is incorrect for two reasons. First, it is high in sodium and should not be used by the client with hypertension. In addition, it is a lower source of carbohydrate, providing only 5 g per ½ cup. |
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A Client has been diagnosed with goiter. The nurse should expect to note which of the following documented in the client’s record? |
Enlarged Thyroid Gland Rationale: Goiter is an enlargement of the thyroid gland. Enlargement occurs in an attempt to compensate for hormone deficiency. Heart damage, chronic fatigue, and decreased wound healing are not specifically associated with goiter. |
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A nursing is caring for a hospitalized older client with diabetes mellitus who is diagnosed with dehydration. The Client is alert but disoriented, pale, and slightly diaphoretic; and the nurse suspects that the client is hypoglycemic. The initial nursing intervention is to: |
Obtain a fingerstick blood sample and test the glucose level. Rationale: The nurse should confirm that the client is hypoglycemic by checking the blood glucose. Option 1 is incorrect because the hypoglycemia has not been determined. More information should be gathered before calling the physician |
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A nurse is planning to care for a client with Cushing’s syndrome. The nurse plans care knowing that that condition is caused by: |
Excessive amounts of Cortisol Rationale: Cushing’s syndrome is caused by excessive amounts of cortisol. The average age of onset is between 20 and 40 years, and it occurs more commonly in women than in men. |
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Cushing syndrome |
Occurs when your body is exposed to high levels of the hormone cortisol for a long time. The most common cause of Cushing syndrome, sometimes called hypercortisolism, is the use of oral corticosteroid medication. The condition can also occur when your body makes too much cortisol. Too much cortisol can produce some of the hallmark signs of Cushing syndrome — a fatty hump between your shoulders, a rounded face, and pink or purple stretch marks on your skin. Cushing syndrome can also result in high blood pressure, bone loss and, on occasion, diabetes. Treatments for Cushing syndrome can return your body’s cortisol production to normal and noticeably improve your symptoms. The earlier treatment begins, the better your chances for recovery |
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Addison’s disease |
Addison’s disease is a disorder that occurs when your body produces insufficient amounts of certain hormones produced by your adrenal glands. In Addison’s disease, your adrenal glands produce too little cortisol and often insufficient levels of aldosterone as well. Also called adrenal insufficiency, Addison’s disease occurs in all age groups and affects both sexes. Addison’s disease can be life-threatening. Treatment for Addison’s disease involves taking hormones to replace the insufficient amounts being made by your adrenal glands, in order to mimic the beneficial effects produced by your naturally made hormones. |
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A nurse is providing home care instruction to a client with a diagnosis of Addison’s disease. Which client statement indicates a need for further instruction? |
I should daily medication for a limited period Rationale: Addison’s disease is a life-threatening condition caused by partial or complete failure of adrenocortical function. Client education includes the need for lifelong daily medications. The client is also instructed to carry or wear a Medic-Alert card or bracelet. Increased glucocorticoid dosage during stressful minor illnesses is necessary. A travel kit needs to be purchased that contains oral cortisone along with intramuscular preparations for self-injection and intravenous vials for emergency injection by a physician. |
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To promote a successful postoperative recovery for a client who had one adrenal gland removed, the nurse plans to reinforce which of the following instructions? |
Instructions about early signs of a wound infection Rationale: A client who is undergoing a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until discontinued. Because of the antiinflammatory properties of corticosteroids, clients who undergo adrenalectomies are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present. |
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A Client with Cushing’s syndrome is being instructed by the nurse about follow-up care. Which statement by the client indicates a need for further instruction? |
"I should avoid food rich in Potassium" Rationale: Cushing’s syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol by the adrenal cortex. Hypokalemia is associated with this condition, and the client should consume foods high in potassium. Clients experience activity intolerance, osteoporosis, and frequent bruising. Fluid volume excess results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion. |
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Which of the following laboratory data indicate a potential complication associated with type 1 diabetes mellitus? |
Ketonuria is an abnormal finding in the diabetic client that indicates ketosis. Ketosis is a metabolic effect from the lack of insulin on fat metabolism and occurs in type 1 diabetes mellitus. It is associated with severe complications of diabetic ketoacidosis (hyperglycemia, ketosis, and acidosis). |
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A nurse is collecting data from a male client with diabetes mellitus who has been taking insulin for many years. The client states that currently he is experiencing periods of hypoglycemia. The nurse determines that the most likely cause for this occurrence is |
Injection insulin at the site of lipodystrophy Rationale: Tissue hypertrophy (lipodystrophy) involves thickening of the subcutaneous tissue at the injection sites. This can interfere with the absorption of insulin, resulting in erratic blood glucose levels. Because the client has been on insulin for many years, this is the most likely cause of poor control. |
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A nurse is assisting in planning care for the client with aldosteronism. The nurse plans to monitor for which of the following in the client |
Fluid overload Rationale: Aldosteronism is a condition characterized by hypersecretion of aldosterone. Aldosterone plays a major role in fluid and electrolyte balance. Hypersecretion of aldosterone leads to sodium and water retention, which can lead to fluid overload. The other options are not part of the clinical picture that occurs with this health problem. |
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A Nurse is monitoring a client with Addison’s disease for signs of hyperkalemia. The nurse expects to note which of the following if hyperkalemia is present? |
Cardiac dysrhythmias Rationale: Addison’s disease is a condition caused by partial or complete failure of adrenocortical function. The inadequate production of aldosterone in Addison’s disease causes inadequate excretion of potassium and results in hyperkalemia. The clinical manifestations of hyperkalemia are the result of altered nerve transmission. The most harmful consequence of hyperkalemia is its effect on cardiac function. Options 1, 3, and 4 are not manifestations associated with Addison’s disease or hyperkalemia. |
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A nurse is assisting with admitting a client to the hospital who recently had a bilateral adrenalectomy. Which intervention is essential for the nurse to suggest to include in the client’s plan of care? |
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A nurse is assisting with admitting a client to the hospital who recently had a bilateral adrenalectomy. Which intervention is essential for the nurse to suggest to include in the client’s plan of care? |
Avoid stress-producing situations and procedures Rationale: A bilateral adrenalectomy involves removal of the adrenal glands. This surgical procedure can lead to adrenal insufficiency. Adrenal hormones are essential in maintaining homeostasis in response to stressors. |
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A nurse who is caring for a client with Graves’ disease notes a nursing diagnosis of Imbalanced Nutrition: Less Then Body Requirements related to the effects of the hypercatabolic state in the care plan. Which of the following indicates a successful outcome for this diagnosis? |
The client maintains his or her normal weight or gradually gains weight if it is below normal. Rationale: Graves’ disease is characterized by hyperthyroidism. It causes a state of chronic nutritional and caloric deficiency as a result of the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite. Therefore it is a nutritional goal that the client will not lose additional weight and will gradually return to the ideal body weight if necessary. To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks. The relationship between mealtime and the blood glucose level is unrelated to the subject of the question. |
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A Client with type 2 diabetes mellitus was recently hospitalized for hyperglycemic hyperosmolar nonketotic syndrome (HHNS). On discharge from the hospital, the client expresses concern about the recurrence of HHNS. Which statement by the nurse is therapeutic? |
"You have concerns about the treatment for your condition" Rationale: The nurse should provide time and listen to the client’s concerns. In option 4 the nurse is attempting to clarify the client’s feelings. Options 1 and 2 provide inappropriate false reassurance. In addition, the nurse does not tell the client not to worry. Option 3 is not an appropriate nursing response. It disregards the client’s concerns and gives advice. |
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hyperglycemic hyperosmolar nonketotic syndrome (HHNS) |
Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious condition most frequently seen in older persons. HHNS can happen to people with either type 1 or type 2 diabetes that is not being controlled properly, but it occurs more often in people with type 2. HHNS is usually brought on by something else, such as an illness or infection. In HHNS, blood sugar levels rise, and your body tries to get rid of the excess sugar by passing it into your urine. You make lots of urine at first, and you have to go to the bathroom more often. Later you may not have to go to the bathroom as often, and your urine becomes very dark. Also, you may be very thirsty. Even if you are not thirsty, you need to drink liquids. If you don’t drink enough liquids at this point, you can get dehydrated. If HHNS continues, the severe dehydration will lead to seizures, coma and eventually death. HHNS may take days or even weeks to develop. Know the warning signs of HHNS. What are the Warning Signs? * Blood sugar level over 600 mg/dl * Dry, parched mouth * Extreme thirst (although this may gradually disappear) * Warm, dry skin that does not sweat * High fever (over 101 degrees Fahrenheit, for example) * Sleepiness or confusion * Loss of vision * Hallucinations (seeing or hearing things that are not there) * Weakness on one side of the body |
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A nurse is monitoring a hospitalized client with diabetes mellitus for signs of hyperglycemia. |
1. Excessive thirst 2. Increased urine output 3. Kussmaul’s respiration Rationale: Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul’s respirations, diuresis, and coma, when severe. If the client presents with these symptoms, the blood glucose level should be checked immediately. Hunger, sweating, and diaphoresis are signs of hypoglycemia. |
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Kussmaul respiration |
Is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also renal failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration. In metabolic acidosis, breathing is first rapid and shallow[1] but as acidosis worsens, breathing gradually becomes deep, labored and gasping. It is this latter type of breathing pattern that is referred to as Kussmaul breathing. |
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A client with diabetes mellitus is brought to the urgent care center by the family. The client is lethargic and complains of a dry mouth and thirst. The skin is warm and dry, skin turgor is poor, and the client has deep respiration and a fruity odor to the breath. The nurse concludes that the client is experiencing which complication of diabetes mellitus? |
Diabetic Ketoacidosis Rationale: Diabetic ketoacidosis is a complication of uncontrolled diabetes mellitus and is characterized by signs of dehydration such as dry mouth, thirst, and poor skin turgor. The client’s neurological status declines as the serum glucose level rises. The pulse becomes rapid and weak, whereas the respirations become deep. The breath has a fruity or acetone odor to it. The client also may complain of abdominal pain, nausea, and vomiting. |
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A nurse has taught the principles of foot care to a client with diabetes mellitus. The nurse determines that the client understood the information if the client states to: |
Wear shoes that are closed toe and heal. Rationale: The client should wear shoes that are closed at the heel and toe to prevent injury to the feet. The client should avoid other potential sources of injury to the feet. Application of direct heat to the feet could cause burns, and application of lotion between the toes could cause skin breakdown. Toenails should be cut straight across at the level of the contour of the toe. Other general foot care measures include inspecting the feet daily, cleaning them with mild soap, rinsing and drying them well, and using lanolin-based lotions, except between the toes. |
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The nurse has taught a client newly diagnosed with diabetes mellitus about blood glucose monitoring. The nurse determines that the client understand the information client states to report blood glucose levels that exceed: |
250 mg/dL. Rationale" It is standard practice to teach the client to report blood glucose levels that exceed 250 mg/dL unless otherwise instructed by the physician. |
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A client with hyperaldosteronism has undergone unilateral adrenalectomy. The nurse includes which of the following items in postoperative teaching? |
Glucocorticoids will be needed temporaily Rationale: The client who has undergone unilateral adrenalectomy must take replacement corticosteroids for up to 2 years after surgery. This allows the remaining gland to resume function after being suppressed by the excessive hormone production of the diseased gland. Diuretics and a low-sodium diet are used in the preoperative period to manage hypertension. Once surgery has been performed, these measures are no longer required. |
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The reviews the client’s laboratory results and reports which abnormal value to the physician? |
Blood urea nitrogen Rationale: The normal calcium level is 8.6 to 10 mg/dL. The normal magnesium level is 1.8 to 3 mg/dL. The normal potassium level is 3.5 to 5.1 mEq/L. The normal blood urea nitrogen is 5 to 20 mg/dL. |
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Bilateral Adrenalectomy |
Definition Adrenalectomy is the surgical removal of one or both of the adrenal glands. The adrenal glands are paired endocrine glands, one located above each kidney, that produce hormones such as epinephrine, norepinephrine, androgens, estrogens, aldosterone, and cortisol. Adrenalectomy is usually performed by conventional (open) surgery, but in selected patients surgeons may use laparoscopy. With laparoscopy, adrenalectomy can be accomplished through four very small incisions. Purpose Adrenalectomy is usually advised for patients with tumors of the adrenal glands. Adrenal gland tumors may be malignant or benign, but all typically excrete excessive amounts of one or more hormones. A successful procedure will aid in correcting hormone imbalances, and may also remove cancerous tumors that can invade other parts of the body. Occasionally, adrenalectomy may be recommended when hormones produced by the adrenal glands aggravate another condition such as breast cancer. Precautions The adrenal glands are fed by numerous blood vessels, so surgeons need to be alert to extensive bleeding during surgery. In addition, the adrenal glands lie close to one of the body’s major blood vessels (the vena cava), and to the spleen and the pancreas. The surgeon needs to remove the gland(s) without damaging any of these important and delicate organs. |
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A Client has recently undergone bilateral adrenalectomy. The nurse assigned to this client should take which action as part of nursing care? |
Correct Answer is Monitor for signs of hypoglycemia Rationale: Adrenal insufficiency can lead to hypoglycemia. Adrenal insufficiency can result in hypovolemia; thus fluid intake should be encouraged, not restricted. Options 1 and 2 are unrelated to the problem of adrenal insufficiency. |
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A nurse is reinforcing medication instructions for a client with hypothyroidism. The nurse reminds the client that levothryoxine sodium (Synthroid) will result in: |
Correct Answer is Increased energy level Rationale: Levothyroxine sodium is a synthetically prepared thyroid hormone that increases body metabolism and the client’s energy level. It promotes weight loss and increases body temperature. It does not affect gastric acid production. |
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A registered nurse tells a licensed practical (LPN) nurse that a client with diabetes mellitus who is taking insulin is beginning to have hypoglycemic reaction and that the nurse should get the client a snack. Which food item would be the best choice? |
Correct Answer is Orange Juice Rationale: A 10- to 15-g simple carbohydrate snack works quickly to increase the blood glucose level. The incorrect options do not provide sufficient simple carbohydrates to produce a quick rise in the blood glucose level. Solid foods take more time to digest than a liquid. Diet ginger ale does not contain sugar. Orange juice contains more sugar than ½ teaspoon sugar. |
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A client with myxedema has developed impaired memory, inattentiveness, and lethargy. The family is distraught about the decline in the client’s intellectual functioning. Which appropriate statement should the nurse make? |
Correct Answer is "It is obvious to me that you are concerned but these symptoms occur with myxedema and should improve with treatment" Rationale: The appropriate response acknowledges the family’s concerns and provides accurate information about the neurological manifestations of myxedema. With thyroid hormone replacement therapy, the symptoms should decrease, with mentation returning to normal in about 2 weeks. |
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A LPN checks the vitals signs of a client who just underwent parathyroidectomy while the registered nurse takes report from the postanesthesia care unit nurse. The client’s blood pressure is 90/60 mm Hg, and the apical pulse is 102 beats/min |
Correct Answer is Check the back of the dressing for bleeding Rationale: A decrease in blood pressure and tachycardia could indicate postoperative bleeding, which is a complication of a parathyroidectomy. Because blood often trickles around the neck to the back, it cannot be observed on the front of the dressing. Thus the first action of the nurse should be to check the front, sides, and back of the dressing and the sheets underneath the neck. The nurse would then report all of the data collected to the RN for further action. |
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A client with hyperthroidism has just discussed an upcoming thyroidectomy with the physician. The client tells the nurse that it is frightening to think about someone cutting into the neck. The nurse should make which response to the client? |
Correct Answer is "Can you describe a little more about what you are frigthening you?’ Rationale: Focusing on the client helps promote effective communications within a therapeutic relationship. |
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A client recently diagnosed with type 1 diabetes mellitus tells the nurse that he is anxious about proper diabetic self-management during an upcoming 6-hour airplane flight. |
Correct answer is Keep snacks in a carry-on luggage to prevent hypoglycemia during flight. Rationale: One of the biggest concerns for persons with diabetes during air travel, especially for long distance flights, is the availability of food at times that correspond with the timing and peak action of the client’s insulin. For this reason the nurse may suggest that the client have carbohydrate snacks on hand for use as needed. Insulin equipment and supplies should always be placed in carry-on luggage (not stowed). This provides ready access to treat hyperglycemia, if needed, and also prevents loss of equipment if luggage is lost. |
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An older client with diabetes mellitus has difficulty seeing the calibration marks on a syringe and cannot accurately draw up the daily NPH insulin dose. The client is expressing doubt about self-management of this disorder, and client’s only close relative lives 30 minutes away. The LPN reports the client’s concern to the RN and suggests a plan to investigate which option before the client’s discharge from the hospital? |
Correct Answer is Obtain a referral to a home health agency for pre-filling syringes and on going support Rationale: The strategic information in this question includes the client’s physical inability to draw up the medication, the self-doubt about the ability to manage the diabetes mellitus, and the unavailability of the family member. |
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A Client is being treated with Levothyroxine Sodium (Synthroid). The nurse tells the client that which of the following is a possible medication side effect |
Correct Answer is Chest Pain Rationale: Levothyroxine sodium (Synthroid) is a synthetic thyroid preparation. Thyroid preparations increase metabolic rate, oxygen demands, and heart burden, which can result in angina pectoris. Options 1, 2, and 4 result from a deficit of thyroid hormone. |
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A nurse is caring for a client with Addison’s Disease and reviews the plan of care. Which intervention will assist in preventing disease compilations? |
Correct Answer is Monitor Blood glucose Rationale: The decrease in cortisol secretion that characterizes Addison’s disease can result in hypoglycemia. Therefore monitoring the blood glucose will assist in identifying the potential for this complication. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of the hyperkalemia that occurs in this condition. Option 3 is not a priority for this client. |
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A nurse is caring for a client with diabetic ketoacidosis (DKA) who has been placed on an intravenous insulin infusion. The nurse reviews the plan of care and prepares to monitor which serial laboratory result as it becomes available? |
Correct Answer is Potassium Level Rationale: The client with DKA becomes hyperkalemic initially as potassium leaves the cells in response to a lowered pH. However, the potassium level drops quickly once the client is treated with fluid replacement and insulin therapy. This is because potassium is carried into the cells along with glucose and insulin and also because potassium is excreted in the urine once rehydration has occurred. Thus the nurse must plan to carefully monitor the results of serum potassium levels. Options 1, 2, and 4 are unrelated to the client’s diagnosis. |
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A licensed practical nurse enters the room of a client with Diabetes mellitus and finds the client difficult to arouse, with warm flushed skin. The pulse and respiratory rate are elevated from the clients baseline. The LPN reports the findings to the registered nurse and prepares to assist in implementing which action first? |
Correct Answer is Checking the client’s capillary blood glucose Rationale: The client’s signs and symptoms are consistent with hyperglycemia. The nurse must first obtain a blood glucose reading and then report it to the physician for subsequent orders. The physician orders an insulin drip if needed. Options 2 and 3 are implemented as needed in the treatment of hypoglycemia. |
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A licensed practical nurse is caring for an older client with diabetic retinopathy secondary to type 2 diabetes mellitus. The LPN plans to address which nursing diagnosis formulated by the registered nurse as the highest priority for client? |
Correct Answer is Risk of injury related to decreased visual acuity Rationale: The individual with retinopathy suffers from varying degrees of visual impairment. Thus falls are a major concern, especially for the older client. Safety takes precedence over self-esteem and body image, thus eliminating options 1 and 3. Option 2 is incorrect because retinopathy is a painless pathological condition of diabetes mellitus. |
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A licensed practical nurse LPN is caring for an older client who has hyperparathyroidism with severe osteoporosis. The LPN plans to address which nursing diagnosis formulated by the registered nurse as the highest priority for this client? |
Correct Answer is Risk of Injury related to demineralization of bone that can result in pathological fractures. Rationale: The individual with hyperparathyroidism with severe osteoporosis is at risk for pathological fractures because of bone demineralization. Thus home safety is a priority. |
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A licensed practical nurse is caring for a client with myxedema. The LPN notes that the registered nurse has identified a nursing diagnosis of Imbalanced Nutrition. Which food sources are appropriate to include in the client’s dietary plan? |
Correct Answer is Skim milk, apples, whole grain bread and cereal Rationale: Myxedema is the most severe form of hypothyroidism. A client with myxedema experiences an alteration in nutrition related to a decreased metabolic need. This client should consume low-calorie foods from all food groups to provide the necessary nutrients. Only option 2 identifies food choices low in calories. |
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A nurse is preparing to administer medications to a client with hypoparathyroidism who has hypocalcemia. The nurse avoids giving the client a vitamin and calcium supplement with which of the following liquids? |
Correct Answer is Milk Rationale: The client with hypoparathyroidism should avoid milk products, which are high in phosphates. Options 1, 2, and 3 are appropriate liquids to administer with a vitamin and calcium supplement. |
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A nurse is reinforcing teaching with a client newly diagnosed with diabetes mellitus who is taking NPH insulin daily in the morning. The nurse tells the client to self-monitor for which of the following signs and symptoms in the late afternoon? |
Correct Answer is Hunger, Shakiness and cool clammy skin Rationale: The client taking NPH insulin experiences peak effects of the medication from 6 to 12 hours after administration. The client is at risk for hypoglycemia at the time the medication peaks if food intake is insufficient. The nurse tells the client to watch for signs and symptoms of hypoglycemia during this time, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweats, headache, increased pulse, shakiness, and hunger. The other options list signs and symptoms of hyperglycemia. |
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A Client experienced an acetylsalicylic (Aspirin) acid overdose 24 hours before being admitted to the hospital. The nurse monitors the client for signs and symptoms of which of the following acid-base imbalances? |
Correct Answer is Metabolic acidosis Rationale: Acetylsalicylic acid is aspirin, which leads to metabolic acidosis as a late complication. In the early phase after aspirin overdose, the client may experience respiratory alkalosis as a compensatory mechanism as the body tries to combat the developing metabolic acidosis. Options 1, 2, and 4 are incorrect. |
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A client is admitted to the hospital with severe hypoparathyriodism. The nurse plans to do which of the following to promote client safety? |
Correct Answer is Institute Seizure precautions Rationale: Hypoparathyroidism results from insufficient parathyroid hormone, leading to low serum calcium levels. Hypocalcemia can cause tetany, which can lead to seizures if untreated. The nurse should institute seizure precautions to maintain a safe environment. Options 1, 3, and 4 are unrelated to the client’s diagnosis. |
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A Client has received instructions about postoperative care after a parathyroidectomy. Which client action would indicate to the nurse that the client understood the instructions? |
Correct Answer is The client places the hands at the back of the head when moving the neck Rationale: The weight of the client’s head must be supported when the client flexes the neck or moves the head. This decreases the stress on the suture line, which prevents bleeding. Options 2 and 4 are inaccurate and actually could be harmful to the client. Option 3 is not necessary, as the client has an incision in the neck, not the chest. |
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A client with Addison’s disease has been instructed to follow up care to avoid complications. The nurse determines that teaching was effective when the client verbalizes that she will avoid: |
Correct Answer is Becoming dehydrated Rationale: Addison’s disease is a life-threatening condition caused by partial or complete failure of adrenocortical function. Decreased aldosterone secretion results in fluid volume deficit. Clients are encouraged to maintain an oral intake of 3000 mL/day to avoid dehydration. Clients require a high-sodium diet to replace losses. Snacks between meals are encouraged to prevent hypoglycemia. Clients with Addison’s disease require hormone replacement therapy with corticosteroids. |
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A nurse reinforces instructions about the signs of addisonian crisis to client with Addison’s disease. The nurse determines that teaching was effective when the client states that which of the following is a sign of this crisis? |
Correct Answer is Sudden, profound weakness Rationale: Addisonian crisis is a serious, life-threatening response to acute adrenal insufficiency that is most commonly precipitated by a major stressor. The client with addisonian crisis may have any of the symptoms of Addison’s disease, but the primary problems are sudden, profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal shutdown. |
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A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse in the physician’s off that yesterday the late afternoon blood glucose level was 60mg/dL and that he felt funny. Which client statement would indicate an understanding of this occurrence |
Correct Answer is "I forgot to take my usual afternoon snack yesterday" Rationale: Hypoglycemia is a blood glucose of 60 mg/dL or less. The causes are multiple, but in this case omitting the afternoon snack would lead to hypoglycemia. Fatigue and self-adjustment of the insulin dose are incorrect options. Recommended frequency of blood glucose testing is four times a day. |
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A nurse reinforces home care instructions to a client with a diagnosis of primary hyperparathyroidism. Which client statement indicates that the client has a knowledge deficit about treatment of the condition? |
Correct answer is "I urinate frequently, so I take only half of my fluid pill" Rationale: Medical management of hyperparathyroidism includes increasing urinary calcium excretion with diuretics. High-calcium foods should be limited. The psychosocial manifestations associated with the disorder diminish as serum calcium levels are lowered with treatment. |
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Which of the following diagnostic tests would best indicate a reduction in thyroid hormone secretion and synthesis in the client who is in thyroid storm and is being treated with propylthiouracil (PTU) |
Correct Answer is Serum T3 and T4 Rationale: Propylthiouracil (PTU) is administered to clients in thyroid storm to block thyroid hormone synthesis of T3 and T4. Serum thyroid antibodies indicate whether an autoimmune disease is causing the client’s symptoms. A thyroid scan provides information about whether excessive or diminished activity is present in the gland but does not provide information about the degree of hormone synthesis. The thyroid stimulation test differentiates primary from secondary hypothyroidism. |
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A nurse is reviewing assessment findings and laboratory data of a client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Select the clinical manifestations of this disorder. |
Correct Answer is Signs of water intoxication, High urine osmolality, Low serum osmolality and Gastrointestinal disturbances Rationale: SIADH is characterized by inappropriate continued release of antidiuretic hormone (ADH). This results in water intoxication characterized by fluid volume expansion, weight gain, hypotonicity of body fluids, and hyponatremia as a result of the high urine osmolality and low serum osmolality. Gastrointestinal disturbances such as anorexia, nausea, and vomiting occur as early manifestations. |
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A nurse is providing instructions to a client who is schedule for a glucose tolerance test. Which instruction will the nurse provide to the client in preparation for the test. |
Correct Answer is Avoid alcohol, coffee, or tea for 12 hours before testing. Rationale: The nurse instructs the client to consume a high-carbohydrate diet for at least 3 days before the test and to discontinue oral contraceptives, corticosteroids, salicylates, and thiazide derivatives 3 days before the test. The client is told to withhold administration of insulin or oral hypoglycemic agents on the day of the test. Fasting is necessary from midnight before the test and during the test, although water is permitted. Alcohol, coffee, and tea should be avoided for 12 hours before the test. |
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A client suspected of having Cushing’s syndrome is scheduled for adrenal venography, and the nurse has provided instructions to the client about the test. Which client statement indicates a need for further instructions |
Correct Answer is I will be placed in a high sitting position for the test. Rationale: The client is informed that the test aids in determining whether symptoms are caused by abnormalities in the adrenal gland. The nurse assesses the client for allergies to iodine before the test. The client is told that a transient burning sensation may be experienced after the dye is injected, that the client will be placed in a supine position, and that the insertion site will be locally anesthetized. An informed consent form is required. |
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A nurse is assisting in the care of a client with hyperparathyroidism. The nurse does which of the following to help safely minimize effects of the disease process? |
Correct Answer Assist the client to ambulate in the hall 3 times a day for 15 minutes Rationale: The client with hyperparathyroidism is predisposed to hypercalcemia and renal calculi formation; therefore ambulation is important. A diet high in milk products would add to the client’s calcium load. Calcium carbonate contains calcium and is therefore not the best choice as an antacid. Fluids should not be restricted because fluids aid in excreting calcium via the kidneys and prevent the formation of calcium-containing renal stones. |
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A nurse is assisting in planning care for the client with aldosteronism. The nurse should plan to monitor for which of the following? |
Correct Answer is Fluid Overload Rationale: Aldosterone plays a major role in fluid and electrolyte balance. Hypersecretion of aldosterone causes sodium and water retention, which can lead to fluid overload. The other options are not part of the clinical picture of aldosteronism. |
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A nurse is monitoring a hospitalized client with diabetes mellitus for signs of hyperglycemia. Select all signs of hyperglycemia |
Correct Answer is Kussmaul’s respiration, Excessive thirst and Increased urine output Rationale: Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul’s respirations, diuresis, and coma, when severe. If the client presents with these symptoms, the blood glucose level should be checked immediately. Hunger, sweating, and diaphoresis are signs of hypoglycemia. |
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A client with diabetes mellitus has had insulin added to the treatment regimen. The nurse determines that the dose of insulin is optimal if the client has a random blood glucose level of |
Correct Answer is 115mg/dL Rationale: The normal random blood glucose level is 80 to 120 mg/dL, but may vary, depending on the time of the last meal. Options 3 and 4 are incorrect because they exceed the normal range. Option 1 is slightly lower than normal and places the client at risk for hypoglycemia. |
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A Client with diabetes mellitus tells the nurse that she has cut the blood glucose monitoring strips in half lengthwise to save money. The nurse should make which response to the client? |
Correct Answer is A lot of times the blood glucose value is underestimated with such a small area to read Rationale: Visual interpretation of blood glucose monitoring strips by clients can be difficult because of decreased visual acuity levels. Tearing the strips in half may affect the accuracy in reading. Option 1 is inappropriate according to this rationale. Option 2 places a demand on the client. Asking a client "why" needs to be avoided because it requires an explanation from the client and may cause the client to become defensive. |
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