Nokea
Hyperparathyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
- A. Heat intolerance and systolic
- B. Diastolic hypertension and widened hypertension pulse pressure
- C. Weight gain and heat intolerance
- D. Anorexia and hyper-excitability
Correct Answer: A
Rationale: The correct answer is A because hyperparathyroidism is not caused by increased levels of thyroxine but by overactivity of the parathyroid glands. This would lead to symptoms of heat intolerance due to increased metabolism and systolic hypertension due to the effects of excess parathyroid hormone on calcium levels.
Choice B is incorrect because diastolic hypertension and widened pulse pressure are not typical symptoms of hyperparathyroidism. Choice C is incorrect because weight gain is not a common symptom of hyperparathyroidism. Choice D is incorrect because anorexia and hyper-excitability are not typical symptoms of hyperparathyroidism.
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The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
- A. The nurse provides assistance while the patient is walking in the hallways.
- B. The patient is able to ambulate in the hallway with crutches.
- C. The patient will deny pain while walking in the hallway.
- D. The patient’s level of mobility will improve.
Correct Answer: B
Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery.
A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.
Which nursing diagnosis is most appropriate for a client with Addison’s disease?
- A. Risk for infection
- B. Urinary retention
- C. Excessive fluid volume
- D. Hypothermia
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
A guest who is diabetic attended a bridal affair. The guest started to tremble and started to feel dizzy. Luckily a nurse is present. The best action for the nurse to take is to:
- A. encourages the guest to eat some
- B. call the guest’s personal hygiene
- C. offer the guest a peppermint
- D. give the guest a glass of orange juice
Correct Answer: D
Rationale: The correct answer is D: give the guest a glass of orange juice. This is the best action because the guest is likely experiencing hypoglycemia due to being diabetic. Orange juice contains fast-acting sugar that can quickly raise blood sugar levels. Encouraging the guest to eat some (choice A) may take longer to have an effect. Calling the guest's personal hygiene (choice B) is irrelevant to the situation. Offering the guest a peppermint (choice C) will not effectively raise blood sugar levels.
For which of the following problems should the nurse monitor in the patient with multiple myeloma?
- A. Uncontrolled bleeding
- B. Liver engorgement
- C. Respiratory distress
- D. Pathological fractures
Correct Answer: D
Rationale: The correct answer is D: Pathological fractures. In multiple myeloma, abnormal plasma cells can weaken the bones, leading to fractures even with minimal trauma. The nurse should monitor for signs of bone pain, decreased mobility, and pathological fractures to prevent complications.
Uncontrolled bleeding (A) is not typically associated with multiple myeloma. Liver engorgement (B) is more commonly seen in conditions like congestive heart failure or liver disease. Respiratory distress (C) is not a common manifestation of multiple myeloma.
Therefore, the nurse should focus on monitoring for pathological fractures as a priority in a patient with multiple myeloma.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.”
Correct Answer: B
Rationale: The correct answer is B. Polymyositis can affect muscles involved in swallowing, leading to aspiration risk. Therefore, it's crucial for the client to exhibit no signs or symptoms of aspiration. Choice A is unrelated to polymyositis. Choice C involves issues with muscle weakness rather than aspiration risk. Choice D relates to cognitive function, not a common issue with polymyositis.