Nokea
A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient?
- A. Side-lying (lateral) with one pillow under the head
- B. Head of the bed elevated 30 degrees and no pillows placed under the head
- C. Semi-Fowlers with the head supported on two pillows
- D. Supine, with a small roll supporting the neck
Correct Answer: C
Rationale: When moving and turning the patient, the nurse carefully supports the patients head and avoids tension on the sutures. The most comfortable position is the semi-Fowlers position, with the head elevated and supported by pillows.
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You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan?
- A. Risk for injury related to weakness
- B. Ineffective breathing pattern related to muscle weakness
- C. Risk for loneliness related to disturbed body image
- D. Autonomous dysreflexia related to neurologic changes
Correct Answer: A
Rationale: The nursing priority is to decrease the risk of injury by establishing a protective environment. The patient who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners or furniture. The patients breathing will not be affected and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the patient, but safety is a priority.
A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery?
- A. Blood glucose
- B. Assessment of urine for blood
- C. Weight
- D. Oral temperature
Correct Answer: A
Rationale: Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The patients blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication.
The nurse is performing a shift assessment of a patient with aldosteronism. What assessments should the nurse include? Select all that apply.
- A. Urine output
- B. Signs or symptoms of venous thromboembolism
- C. Peripheral pulses
- D. Blood pressure
- E. Skin integrity
Correct Answer: A,D
Rationale: The principal action of aldosterone is to conserve body sodium. Alterations in aldosterone levels consequently affect urine output and BP. The patients peripheral pulses, risk of VTE, and skin integrity are not typically affected.
The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?
- A. Temperature and oxygen saturation
- B. Heart rate and BP
- C. Breath sounds and bowel sounds
- D. Color, warmth, movement, and sensation of extremities
Correct Answer: B
Rationale: The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The patients condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, BP and heart rate monitoring are priorities over the other listed assessments.
A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patients care?
- A. Decisional conflict related to treatment options
- B. Spiritual distress related to changes in cognitive function
- C. Disturbed body image related to changes in physical appearance
- D. Powerlessness related to disease progression
Correct Answer: C
Rationale: Cushing syndrome causes characteristic physical changes that are likely to result in disturbed body image. Decisional conflict and powerless may exist, but disturbed body image is more likely to be present. Cognitive changes take place in patients with Cushing syndrome, but these may or may not cause spiritual distress.