Nokea
A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take?
- A. I must wash the incision with peroxide and redress it daily
- B. I shall cough and deep breathe every 2 hours while I am awake
- C. Avoid activities that increase intracranial pressure
- D. Apply petroleum jelly to lips to avoid dryness
Correct Answer: C
Rationale: After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist, bearing down, coughing, or lying flat. With this approach, there is no incision to clean and dress. Protection from sun exposure is not necessary after this procedure.
You may also like to solve these questions
A nurse cares for a client with a growth hormone deficiency. Which action should the nurse include in this client's plan of care?
- A. Avoid intramuscular medication
- B. Place the client in protective isolation
- C. Use a lift sheet to re-position the client
- D. Monitor growth hormone levels regularly
Correct Answer: C
Rationale: Clients with growth hormone deficiency may have weakened bones due to reduced bone density. Using a lift sheet to reposition the client minimizes the risk of fractures or injury during movement, which is a priority in care planning.
A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws a pitcher against the wall. She then tells the nurse, 'I feel like I am going crazy.' How should the nurse respond?
- A. I will ask your doctor to order a psychiatric consult for you
- B. Your behavior is a result of your condition and will improve with treatment
- C. I will close the door to your room and restrict visitors
Correct Answer: B
Rationale: Hypercortisolism can cause the client to exhibit neurotic to psychotic behavior due to elevated cortisol levels. The client needs to understand that this behavior is a result线�1:27 PM 7/1/2025 result of their condition and will improve with treatment. A psychiatric consult, support groups, or restricted visitors are not necessary at this time.
After teaching a client with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I will no longer need to limit my fluid intake after surgery
- B. I am glad no visible incision will result from this surgery
- C. I will wear slip-on shoes after surgery to limit bending over
- D. I must avoid coughing to prevent complications
Correct Answer: C
Rationale: Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible. It is appropriate for the client to drink as needed postoperatively and to avoid bending over to prevent increased intracranial pressure. However, stating that they will wear slip-on shoes to limit bending over is correct, but the phrasing in option C suggests a misunderstanding if it implies no other precautions are needed.
How should the nurse interpret these results?
- A. Pituitary Hyperfunction
- B. Pituitary hypofunction
- C. Pituitary-induced diabetes mellitus
- D. Normal pituitary response to insulin
Correct Answer: D
Rationale: Some tests for pituitary function involve administering agents that are known to stimulate the secretion of specific pituitary hormones and then measuring the response. Such tests are termed stimulation tests. The stimulation test for GH or ACTH assessment involves injecting the client with regular insulin (0.05 to 1 unit/kg of body weight) and checking circulating levels of GH and ACTH. A normal response indicates adequate pituitary function.
A nurse plans care for a client with Cushing's disease. Which action should the nurse include in this client's plan of care to prevent injury?
- A. Pad the siderails of the client's bed
- B. Assist the client to change positions slowly
- C. Use a lift sheet to change the client's position
- D. Place the client in a position with the head of the bed elevated
Correct Answer: C
Rationale: Cushing's syndrome or disease greatly increases the serum levels of cortisol, which contributes to excessive bone demineralization and increases the risks for pathologic bone fracture. Using a lift sheet to change the client's position minimizes the risk of fractures, providing the most effective protection compared to other options.