Nokea
A client reports that she has gained weight and that her face and body are 'rounder,' while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. When examining this client, the nurse would expect to find:
- A. Orthostatic hypotension.
- B. Muscle hypertrophy in the extremities.
- C. Bruised areas on the skin.
- D. Decreased body hair.
Correct Answer: C
Rationale: Cushing's disease causes thin, fragile skin due to excess cortisol, leading to easy bruising.
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The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
A client with a fractured right femur has not had any immunizations since childhood. Which of the following biological products should the nurse administer to provide the client with passive immunity for tetanus?
- A. Tetanus toxoid.
- B. Tetanus antigen.
- C. Tetanus vaccine.
- D. Tetanus antitoxin.
Correct Answer: D
Rationale: Tetanus antitoxin provides passive immunity, neutralizing existing toxin in unvaccinated clients.
When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by:
- A. Left ventricular overload.
- B. Impending circulatory collapse.
- C. Extracellular electrolyte imbalances.
- D. Insufficient oxygen reaching the heart muscle.
Correct Answer: D
Rationale: MI pain results from myocardial ischemia due to insufficient oxygen delivery to the heart muscle, caused by coronary artery occlusion.
Which position is best for a client with a hemorrhagic stroke?
- A. Flat supine.
- B. Head elevated 30 degrees.
- C. Prone position.
- D. Trendelenburg position.
Correct Answer: B
Rationale: Head elevation at 30 degrees reduces intracranial pressure while maintaining cerebral perfusion in hemorrhagic stroke.
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses and treats bleeding, blood products (C) correct hypovolemia, and a Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention.