Nokea
A client sustained a head injury when falling from a ladder. While in the hospital, the client begins voiding large amounts of clear urine and reports being very thirsty. The client states feeling weak and having experienced an 8 pound weight loss since admission. What condition does the nurse expect the client to be tested for?
- A. Diabetes insipidus (DI)
- B. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
- C. Pituitary tumor
- D. Hypothyroidism
Correct Answer: A
Rationale: With diabetes insipidus, urine output may be as high as 20 L/24 hours. Urine is dilute, with a specific gravity of 1.002 or less. Limiting fluid intake does not control urine excretion. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weakness, dehydration, and weight loss develop. SIADH will have the opposite clinical manifestations. The client's symptoms are related to the trauma and not to a pituitary tumor. The thyroid gland does not cause these symptoms.
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A client has been diagnosed with myxedema from long-standing hypothyroidism. What clinical manifestation(s) of this disorder does the nurse recognize is progressing to myxedema coma? Select all that apply.
- A. Hypothermia
- B. Hypertension
- C. Hypotension
- D. Hypoventilation
- E. Hyperventilation
Correct Answer: A,C,D
Rationale: Severe hypothyroidism is called myxedema. Advanced, untreated myxedema can progress to myxedema coma. Signs of this life-threatening event are hypothermia, hypotension, and hypoventilation. Hypertension and hyperventilation indicate increased metabolic responses, which are the opposite of what the client would be experiencing.
The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with?
- A. Hypothyroidism
- B. Hyperthyroidism
- C. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
- D. Diabetes insipidus (DI)
Correct Answer: B
Rationale: Clients with hyperthyroidism characteristically are restless despite feeling fatigued and weak, highly excitable, and constantly agitated. Fine tremors of the hand occur, causing unusual clumsiness. The client cannot tolerate heat and has an increased appetite but loses weight. Diarrhea also occurs. Visual changes, such as blurred or double vision, can develop. Exophthalmos, seen in clients with severe hyperthyroidism, results from enlarging muscle and fatty tissue surrounding the rear and sides of the eyeball. Hypothyroidism clinical manifestations are the opposite of what is seen in hyperthyroidism, and SIADH and DI clinical manifestations do not correlate with the symptoms manifested by the client.
A client is receiving a test to determine adrenal function. What medication does the nurse administer as a screening test?
- A. Cosyntropin
- B. Sodium bicarbonate
- C. Fludrocortisone
- D. Glucagon
Correct Answer: A
Rationale: A dose of synthetic ACTH, cosyntropin, is administered intramuscularly as a screening test for adrenal function. The other medications are not screening medications to determine adrenal function.
The nurse is caring for a client with hypoparathyroidism. When the nurse taps the client's facial nerve, the client's mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels?
- A. Positive Chvostek sign
- B. Positive Trousseau sign
- C. Positive paresthesia
- D. Positive Babinski sign
Correct Answer: A
Rationale: If a nurse taps the client's facial nerve (which lies under the tissue in front of the ear), the client's mouth twitches and the jaw tightens. The response is identified as a positive Chvostek sign. A positive Trousseau sign is elicited by placing a BP cuff on the upper arm, inflating it between the systolic and diastolic BP, and waiting 3 minutes. The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Positive Babinski sign is elicited by stroking the sole of the foot. Paresthesia is not a symptom that can be elicited; it is felt by the client.
A client with severe hypoparathyroidism is experiencing tetany. What medication, prescribed by the physician for emergency use, will the nurse administer to correct the deficit?
- A. Sodium bicarbonate
- B. Fludrocortisone
- C. Calcium gluconate
- D. Methylprednisolone
Correct Answer: C
Rationale: Tetany and severe hypoparathyroidism are treated immediately by the administration of an IV calcium salt, such as calcium gluconate. The other medications are not effective for the treatment of calcium deficit.