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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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A client has developed oral mucositis as a result of radiation to the head and neck. Which measure should the nurse teach the client to incorporate in a daily home care routine to help manage this condition?
- A. A glass of wine per day will introduce useful bacterial to the oral cavity.
- B. High-protein foods such as peanut butter should be incorporated in the diet.
- C. Clean teeth and rinse mouth with a weak saline and water solution before and after each meal.
- D. Oral hygiene, including brushing and flossing, should be performed in the morning and evening.
Correct Answer: C
Rationale: Oral mucositis (irritation, inflammation, and/or ulceration of the mucosa) also known as stomatitis, commonly occurs in clients receiving radiation to the head and neck. Measures need to be taken to soothe the mucosa and provide effective cleansing of the oral cavity. A combination of a weak saline and water solution is an effective cleansing agent. Oral hygiene should be performed more frequently than in the morning and evening. Alcohol would dry and irritate the mucosa and not affect the oral bacteria. Peanut butter has a thick consistency and will stick to the irritated mucosa.
A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. Which nursing measure should the nurse implement to increase the client's comfort until specific therapy is prescribed by the primary health care provider?
- A. Cover the client with warm blankets.
- B. Minimize visual and auditory stimuli present.
- C. Elevate the client's head to at least 45 degrees.
- D. Administer oxygen at 4 L per minute by nasal cannula.
Correct Answer: C
Rationale: Excess fluid volume can lead to symptoms such as shortness of breath and cerebral edema, which can be alleviated by elevating the head of the bed to at least 45 degrees to promote venous drainage and reduce intracranial pressure. This is a safe and effective nursing intervention to increase comfort until specific medical therapy is prescribed.
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.
Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that her skin has become very red and is beginning to peel?
- A. Discontinue the medication immediately.
- B. Come to the clinic immediately for an assessment.
- C. I'll notify your primary health care provider of these results.
- D. This is a normal occurrence with the use of this medication.
Correct Answer: D
Rationale: Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. Options 1, 2, and 3 are incorrect statements to the client.
A clinic nurse is assessing a prenatal client who has been diagnosed with heart disease. The nurse carefully assesses the client's vital signs, weight, and fluid and nutritional status to detect for complications caused by which pregnancy-related concern?
- A. Rh incompatibility
- B. Fetal cardiomegaly
- C. The increase in circulating blood volume
- D. Hypertrophy and increased contractility of the heart
Correct Answer: C
Rationale: Pregnancy taxes the circulating system of every woman because the blood volume increases, which causes the cardiac output to increase. Stroke volume × heart rate = cardiac output (SV × HR = CO). Options 1, 2, and 4 are not directly associated with pregnancy in a client with a cardiac condition.