Nokea
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.
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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 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.
A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.)
- A. Thyroid-stimulating hormone
- B. Vasopressin
- C. Follicle-stimulating hormone
- D. Calcitonin
- E. Growth hormone
Correct Answer: A,C,E
Rationale: The anterior pituitary gland secretes thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone, which would be affected by hypofunction. Vasopressin and calcitonin are secreted by the posterior pituitary and thyroid gland, respectively.
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 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.