Nokea
A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client?
- A. How do you plan to pay for your treatments?
- B. How do you feel about yourself?
- C. What medications are you prescribed?
- D. What are you doing to prevent this from happening?
Correct Answer: B
Rationale: Hirsutism, or excessive hair growth, can result from endocrine disorders and may cause a disruption in body image, especially for female clients. Asking about self-perception addresses the psychosocial impact of the condition.
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A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, Why do I need to collect urine for 24 hours instead of providing a random specimen? How should the nurse respond?
- A. The hormone is secreted on a circadian rhythm.
- B. The hormone is diluted in urine, therefore, we need a large volume.
- C. We are assessing when the hormone is secreted in large amounts.
- D. To collect the correct hormone, you need to urinate multiple times.
Correct Answer: A
Rationale: Hormones are secreted in a pulsatile or circadian cycle. A 24-hour urine collection provides a more accurate reflection of hormone secretion over time compared to a random specimen.
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 evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value should the nurse assess first?
- A. Posterior pituitary hormones
- B. Adrenal medulla hormones
- C. Anterior pituitary hormones
- D. Parathyroid hormone
Correct Answer: C
Rationale: Breast fluid secretion in males is often due to elevated prolactin levels, which is secreted by the anterior pituitary gland. Assessing anterior pituitary hormones is the priority.
A nurse cares for a client with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance should the nurse assess?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Magnesium
Correct Answer: C
Rationale: Parafollicular cells produce thyrocalcitonin (calcitonin), which regulates serum calcium levels. Excessive calcitonin can lead to hypocalcemia by inhibiting bone resorption and increasing calcium excretion.
A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next?
- A. Ask the UAP if he washed his hands afterward.
- B. Have the UAP fill out an incident report.
- C. Ask the laboratory if the container has preservative in it.
- D. Send the UAP to Employee Health right away.
Correct Answer: A
Rationale: The nurse should ensure the UAP washed their hands to follow Standard Precautions and remove any potential preservative, which may be caustic. This is the immediate safety priority.