Nokea
A client with a history of Addison's disease is admitted with complaints of nausea and vomiting. The nurse should expect the client to have:
- A. Hyperkalemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: A
Rationale: Addison's disease causes adrenal insufficiency, reducing aldosterone, which leads to hyperkalemia due to impaired potassium excretion.
You may also like to solve these questions
A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
- A. Dryness of the skin and mucus membranes
- B. Dizziness when rising to a standing position
- C. A weight gain of six pounds in the past week
- D. Difficulty in remaining asleep
Correct Answer: C
Rationale: Rapid weight gain (6 pounds in a week) suggests fluid retention, a sign of glucocorticoid excess, requiring dosage adjustment. Dizziness may indicate underdosing, and the other symptoms are less specific.
A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which physician's order should the nurse question?
- A. Magnesium sulfate 4 gm (25\%) IV
- B. Brethine (terbutaline) 10 mcg IV
- C. Stadol (butorphanol) 1mg IV push every four hours as needed PRN for pain
- D. Ancef (cefazolin) 2 gm IVPB every six hours
Correct Answer: B
Rationale: Terbutaline (Brethine) a tocolytic is used to stop preterm labor but is contraindicated in diabetic patients due to its risk of causing hyperglycemia. The other medications are appropriate for preeclampsia (magnesium sulfate) pain (butorphanol) or infection prophylaxis (cefazolin).
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Politely tells the client, 'Keep your hands off'
- B. Ignores the remarks and hopes he will not try it again
- C. Confronts the remarks but attempts not to reject the client
- D. Leaves the room in order to compose herself
Correct Answer: C
Rationale: By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship.
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
- A. I did not get the raise because my boss does not like me.'
- B. I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's wedding.'
- C. My son died 3 years ago. I still cannot bring myself to clean out his room.'
- D. My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today.'
Correct Answer: D
Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.
The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
- A. Blood pressure of 140/90
- B. 2+ proteinuria
- C. Headache and visual disturbances
- D. Edema of the hands
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.