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A client diagnosed with myxedema reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? Select all that apply.
- A. Thyroxine (T4)
- B. Prolactin (PRL)
- C. Triiodothyronine (T3)
- D. Growth hormone (GH)
- E. Luteinizing hormone (LH)
- F. Adrenocorticotropic hormone (ACTH)
Correct Answer: A,C
Rationale: Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.
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The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?
- A. A high level of stamina and energy
- B. Self-consciousness about using a cane
- C. Full range of motion in lower extremities
- D. Balance, muscle strength, and confidence
Correct Answer: D
Rationale: Assessing the client's balance, strength, and confidence helps determine if the cane is a suitable assistive device for the client. A high level of stamina and full range of motion are not needed for walking with a cane. Although body image (self-consciousness) is a component of the assessment, it is not the priority.
The nurse preparing to administer an intermittent tube feeding through a nasogastric (NG) tube assesses for residual volume. How do the resulting data assist in assuring the client's safety?
- A. Confirm proper NG tube placement.
- B. Determine the client's nutritional status.
- C. Evaluate the adequacy of gastric emptying.
- D. Assess the client's fluid and electrolyte status.
Correct Answer: C
Rationale: All stomach contents are aspirated and measured before administering a tube feeding to determine the gastric residual volume. If the stomach fails to empty and propel its contents forward, the tube feeding accumulates in the stomach and increases the client's risk of aspiration. If the aspirated gastric contents exceed the predetermined limit, the nurse withholds the tube feeding and collaborates with the primary health care provider on a plan of care. Assessing gastric residual volume does not confirm placement or assess fluid and electrolyte status. The nurse uses clinical indicators, including serum albumin levels, to determine the client's nutritional status.
The nurse in an ambulatory care clinic takes a client's blood pressure (BP) in the left arm; it is 200/118 mm Hg. Which action should the nurse implement next?
- A. Notify the primary health care provider.
- B. Inquire about the presence of kidney disorders.
- C. Check the client's blood pressure in the right arm.
- D. Recheck the pressure in the same arm within 30 seconds.
Correct Answer: C
Rationale: When a high BP reading is noted, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm but would wait at least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The nurse would notify the primary health care provider because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications?
- A. Trim the rough edges of the cast after it is dry.
- B. Weight bearing on the right leg is allowed once the cast feels dry.
- C. Expect burning and tingling sensations under the cast for 3 to 4 days.
- D. Keep the right ankle elevated above the heart level with pillows for 24 hours.
Correct Answer: D
Rationale: Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to 'petal' the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity. Weight bearing on a fractured extremity is prescribed by the primary health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately.
The nurse provides information to a preoperative client who will be receiving relaxation therapy. What effects should the nurse teach the client to expect regarding this type of therapy? Select all that apply.
- A. Increased heart rate
- B. Improved well-being
- C. Lowered blood pressure
- D. Increased respiratory rate
- E. Decreased muscle tension
- F. Increased neural impulses to the brain
Correct Answer: B,C,E
Rationale: Relaxation is the state of generalized decreased cognitive, physiological, and/or behavioral arousal. Relaxation elongates the muscle fibers, reduces the neural impulses to the brain, and thus decreases the activity of the brain and other systems. The effects of relaxation therapy include improved well-being; lowered blood pressure, heart rate, and respiratory rate; decreased muscle tension; and reduced symptoms of distress in persons who need to undergo treatments, those experiencing complications from medical treatment or disease, or those grieving the loss of a significant other. This therapy does not cause an increased heart rate, increased respiratory rate, or increased neural impulses to the brain.