Nokea
The nurse is caring for the client with elevated growth hormone (GH) levels. Which problem should the nurse exclude from the plan of care?
- A. Fluid volume deficit due to polyuria
- B. Insomnia due to soft tissue swelling
- C. Impaired communication due to speech difficulties
- D. Altered body image due to undersized hands, feet, and jaw
Correct Answer: D
Rationale: GH excess causes overgrowth of bones and soft tissues, not undersizing, so altered body image due to undersized features is excluded.
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As the nurse provides care for the client newly diagnosed with a large goiter, which interventions should be implemented? Select all that apply.
- A. Observe the client's respiratory status
- B. Elevate the head of the client's bed
- C. Provide a diet high in food used.
- D. Obtain an order for a soft diet
- E. Assess for high fever
- F. Administer prescribed antibiotics
Correct Answer: A,B,D
Rationale: A large goiter can compress the trachea, necessitating respiratory monitoring, head elevation, and a soft diet to ease swallowing.
What should be included in the nursing care plan for a client with diabetes insipidus?
- A. Blood pressure every hour
- B. Strict intake and output
- C. Urine for ketone bodies
- D. Glucose monitoring four times a day
Correct Answer: B
Rationale: Diabetes insipidus causes excessive urine output due to low antidiuretic hormone, requiring strict intake and output monitoring to assess fluid balance.
The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply.
- A. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days.
- B. Discuss ways to cope with the emotional lability.
- C. Notify the HCP if taking over-the-counter medication.
- D. Carry a medical identification card or bracelet.
- E. Teach how to take thyroid medications correctly.
Correct Answer: B,C,D
Rationale: Coping with emotional lability, reporting OTC meds, and carrying ID address hyperthyroidism’s effects and safety. Rapid weight loss is expected, and thyroid meds are for hypothyroidism.
The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client?
- A. Diabetes insipidus (DI).
- B. Crohn's disease.
- C. Narcotic addiction.
- D. Peritonitis.
Correct Answer: C
Rationale: Chronic pancreatitis often requires long-term pain management, risking narcotic addiction. DI, Crohn’s, and peritonitis are unrelated complications.
Two hours after taking a regular morning dose of regular insulin, the client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate?
- A. Check pulse oximetry; if 94% or less, start oxygen at 2 L per nasal cannula.
- B. Give a baby aspirin and one nitroglycerin tablet; obtain an electrocardiogram.
- C. Check blood glucose level; provide carbohydrates if less than 70 mg/dL (3.8 mmol/L).
- D. Check heart rate; if the HR is above 120 beats per minute, give atenolol 25 mg orally.
Correct Answer: C
Rationale: Regular insulin peaks in 2 to 4 hours after administration. The client's symptoms suggest hypoglycemia, so a blood glucose level should be checked and carbohydrates given if low.