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A nurse assesses a client diagnosed with adrenal hypofunction. Which client statement should the nurse correlate with this diagnosis?
- A. I have a terrible craving for potato chips.
- B. I cannot seem to get enough water.
- C. I no longer have an appetite for anything.
- D. I get hungry even after eating a meal.
Correct Answer: A
Rationale: Adrenal hypofunction can lead to hyponatremia, causing salt cravings, as seen in the clients desire for potato chips.
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A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?
- A. Void the clients first void and collect urine for 24 hours.
- B. Add the preservative to the container at the end of the test.
- C. Start the collection by saving the first urine of the morning.
- D. Ensure the client drinks plenty of water during collection.
Correct Answer: A
Rationale: The 24-hour urine collection begins after discarding the first void to ensure a full 24-hour period of collection. This ensures accurate measurement of excreted substances.
A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergic status nor a significant medical history. Which action should the nurse include in this clients plan of care?
- A. Initiate Airborne Precautions.
- B. Offer fluids every hour or two.
- C. Administer broad-spectrum antibiotics.
- D. Palpate the clients thyroid gland.
Correct Answer: B
Rationale: Decreased antidiuretic hormone (ADH) production is a normal age-related change, leading to increased urine output and risk of dehydration. Offering fluids regularly helps prevent dehydration in older adults.
A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?
- A. Heart rate of 50 beats/min
- B. Respiratory rate of 18 breaths/min
- C. Oxygen saturation of 92%
- D. Blood pressure of 144/69 mm Hg
Correct Answer: A
Rationale: Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions, leading to an increased heart rate and cardiac output. A heart rate of 50 beats/min indicates the client is not responding to the medication, which is a cause for concern.
A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?
- A. Stand in front of the client instead of behind the client.
- B. Ask the client to swallow after palpating the thyroid.
- C. Palpate the right lobe with the nurses left hand.
- D. Place the client in a sitting position with the chin tucked down.
Correct Answer: D
Rationale: The correct technique for thyroid palpation involves the nurse standing behind the client, with the client in a sitting position and chin tucked down to relax the neck muscles, facilitating palpation of the thyroid gland.
A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?
- A. Decreased blood pressure
- B. Increased pulse
- C. Decreased respiratory rate
- D. Increased urine output
Correct Answer: B
Rationale: Catecholamines activate the sympathetic nervous system, leading to tachycardia (increased pulse) as part of the fight-or-flight response.