Nokea
A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis?
- A. Hypovolemia
- B. Hypoglycemia
- C. Mood disturbances
- D. Deficient fluid volume
Correct Answer: C
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol. When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention (hypernatremia), producing edema (hypervolemia; fluid volume excess), and hypertension.
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The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain?
- A. Supine with the knees slightly raised
- B. High Fowler's position with the foot of the bed flat
- C. Semi-Fowler's position with the foot of the bed flat
- D. Semi-Fowler's position with the knees slightly raised
Correct Answer: D
Rationale: Clients with low back pain are often more comfortable in the semi-Fowler's position with the knees raised sufficiently to flex the knees (William's position). This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the bed flat or lying in a supine position with the knees raised would excessively stretch the lower back. Keeping the foot of the bed flat will enhance extension of the spine.
The nurse is measuring the fundal height on a client who is 36 weeks' gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client?
- A. Fear
- B. Anemia
- C. A full bladder
- D. Compression of the vena cava
Correct Answer: D
Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will prevent the problem. Options 1, 2, and 3 are unrelated to this syndrome.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client?
- A. pH 7.52
- B. pH 7.36
- C. pH 7.25
- D. pH 7.20
Correct Answer: A
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.
A client begins to experience a tonic-clonic seizure. Which actions should the nurse take to assure client safety? Select all that apply.
- A. Restrict the client's movements.
- B. Turn the supine client to the side.
- C. Open the unconscious client's airway.
- D. Gently guide the standing client to the floor.
- E. Place a padded tongue blade into the client's mouth.
- F. Loosen any restrictive clothing that the client is wearing.
Correct Answer: B,C,D,F
Rationale: Precautions are taken to prevent a client from sustaining injury during a seizure. The nurse would maintain the client's airway and turn the client to the side. The nurse would also protect the client from injury, guide the client's movements, and loosen any restrictive clothing. Restraints are never used because they could injure the client during the seizure. A padded tongue blade or any other object is never placed into the client's mouth after a seizure begins because the jaw may clench down.
The nurse is reviewing the results of a sweat test performed on a child diagnosed with cystic fibrosis (CF). Which finding should the nurse identify as supporting this diagnosis?
- A. An evening sweat potassium concentration greater than 60 mEq/L
- B. A sweat chloride concentration that is consistently greater 60 mEq/L
- C. An early morning sweat chloride concentration of less than 40 mEq/L
- D. A sweat potassium concentration that is consistently less than 40 mEq/L
Correct Answer: B
Rationale: Cystic fibrosis is a chronic multisystem disorder characterized by exocrine gland dysfunction. A consistent finding of abnormally high chloride concentrations in the sweat is a unique characteristic of CF. Normally the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF. Potassium concentration is unrelated to the sweat test.