Nokea
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.
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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 client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client?
- A. Read the label before using salt substitutes
- B. Do not add salt to your food when you eat
- C. Avoid exposure to sunlight
- D. Take Tylenol instead of aspirin for pain
Correct Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic used to control potassium levels in hyperaldosteronism. Excessive potassium intake, such as from potassium chloride-based salt substitutes, can lead to hyperkalemia, a serious complication. Clients should read labels to avoid such substitutes.
A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of testosterone and growth hormone.
- A. A 36-year-old female who has used oral contraceptives for 5 years
- B. A 42-year-old male who experienced head trauma 3 years ago
- C. A 35-year-old female with hormone delivery to mellitus and iodine
- D. A 64-year-old male with adult-onset diabetes mellitus
Correct Answer: B
Rationale: Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition.
A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first?
- A. I will no longer need to limit my fluid intake after surgery
- B. Document the finding and monitor the client
- C. Take vital signs, including temperature
- D. I will wear slip-on shoes after surgery to limit bending over
Correct Answer: C
Rationale: Nuchal rigidity may indicate a complication such as meningitis or cerebrospinal fluid leak following transsphenoidal hypophysectomy. Taking vital signs, including temperature, is the priority to assess for signs of infection or other systemic issues that require immediate intervention.
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.