Nokea
A client is receiving corticosteroid therapy. Which nursing diagnosis would the nurse be least likely to identify for this client?
- A. Risk for Infection
- B. Disturbed Body Image
- C. Risk for Injury
- D. Deficient Fluid Volume
Correct Answer: D
Rationale: A client who is receiving corticosteroid therapy would be least likely to have a nursing diagnosis of Deficient Fluid Volume. Rather, Excess Fluid Volume would be more appropriate. Risk for Infection related to immunosuppression, Disturbed Body Image related to cushingoid effects, and Risk for Injury related to muscle atrophy and osteoporosis would be appropriate.
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Which of the following hormones are secreted by the adrenal gland? Select all that apply.
- A. Growth hormone
- B. Mineralocorticoids
- C. Glucocorticoids
- D. Prolactin
- E. Oxytocin
Correct Answer: B,C
Rationale: Glucocorticoids and mineralocorticoids are secreted by the adrenal gland. Growth hormone, prolactin, and oxytocin are secreted by the pituitary gland.
Which of the following adrenocortical hormone drugs influence or regulate functions such as the immune response; glucose, fat, and protein metabolism; and the anti-inflammatory response? Select all that apply.
- A. Betamethasone (Celestone)
- B. Fludrocortisone (Florinef)
- C. Budesonide (Entocort EC)
- D. Hydrocortisone (Cortef)
- E. Dexamethasone (Decadron)
Correct Answer: A,C,D,E
Rationale: Glucocorticoids, like betamethasone (Celestone), budesonide (Entocort EC), hydrocortisone (Cortef), and dexamethasone (Decadron), influence or regulate functions such as the immune response; glucose, fat, and protein metabolism; and the anti-inflammatory response.
A nurse suspects that a client taking short-term high-dose methylprednisolone (Medrol) is developing Cushing's syndrome based on assessment of which of the following? Select all that apply.
- A. Weight loss
- B. Moon face
- C. Buffalo hump
- D. Dry skin
- E. Hypotension
Correct Answer: B,C
Rationale: A nurse should monitor a client taking short-term high-dose methylprednisolone (Medrol) for signs and symptoms of Cushing's syndrome, which include buffalo hump, moon face, oily skin, acne, osteoporosis, purple striae on the abdomen and hips, altered skin pigmentation, and weight gain.
A client receiving gonadotropin therapy comes to the clinic for follow-up. Which of the following would the nurse immediately report to the primary health care provider? Select all that apply.
- A. Ascites
- B. Abdominal distention
- C. Abdominal pain
- D. Weight gain
- E. Irritability
Correct Answer: A,B,C
Rationale: The client is at risk for ovarian enlargement manifested by abdominal distention, pain, and ascites (with serious cases). The nurse would immediately notify the primary health care provider and the drug would be discontinued at the first sign of ovarian stimulation or enlargement. Weight gain and irritability would not need to be reported immediately.
A nurse is assessing a client who is receiving desmopressin therapy and suspects that the client is experiencing water intoxication. Which of the following would support the nurse's suspicions? Select all that apply.
- A. Drowsiness
- B. Headache
- C. Confusion
- D. Abdominal pain
- E. Diarrhea
Correct Answer: A,B,C
Rationale: Symptoms of water intoxication include drowsiness, listlessness, confusion, and headache (which may precede convulsions and coma). Abdominal pain and diarrhea are not associated with water intoxication.