Nokea
A patient has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply.
- A. Pupillary response
- B. Creatinine and BUN levels
- C. Potassium level
- D. Peripheral pulses
- E. BP
Correct Answer: C,E
Rationale: Patients with aldosteronism exhibit a profound decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism. Pupillary response, peripheral pulses, and renal function are not directly affected.
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The nurse is planning the care of a patient with hyperthyroidism. What should the nurse specify in the patients meal plan?
- A. A clear liquid diet, high in nutrients
- B. Small, frequent meals, high in protein and calories
- C. Three large, bland meals a day
- D. A diet high in fiber and plant-sourced fat
Correct Answer: B
Rationale: A patient with hyperthyroidism has an increased appetite. The patient should be counseled to consume several small, well-balanced meals. High-calorie, high-protein foods are encouraged. A clear liquid diet would not satisfy the patients caloric or hunger needs. A diet rich in fiber and fat should be avoided because these foods may lead to GI upset or increase peristalsis.
A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a patient with this condition is what?
- A. Risk for peripheral neurovascular dysfunction
- B. Excess fluid volume
- C. Hypothermia
- D. Ineffective airway clearance
Correct Answer: B
Rationale: The priority nursing diagnosis for a patient with SIADH is excess fluid volume, as the patient retains fluids and develops a sodium deficiency. Restricting fluid intake is a typical intervention for managing this syndrome. Temperature imbalances are not associated with SIADH. The patient is not at risk for neurovascular dysfunction or a compromised airway.
Following an addisonian crisis, a patients adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances?
- A. Episodes of high psychosocial stress
- B. Periods of dehydration
- C. Episodes of physical exertion
- D. Administration of a vaccine
Correct Answer: A
Rationale: During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. Physical activity, dehydration and vaccine administration would not normally be sufficiently demanding such to require glucocorticoids.
A patient with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this patient?
- A. Increased body temperature
- B. Jaundice
- C. Copious urine output
- D. Decreased BP
Correct Answer: D
Rationale: Decreased BP may occur with hypofunction of the adrenal cortex. Decreased function of the adrenal cortex does not affect the patients body temperature, urine output, or skin tone.
The nurses assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention?
- A. Oral calcium chloride and vitamin D
- B. IV calcium gluconate
- C. STAT levothyroxine
- D. Administration of parathyroid hormone (PTH)
Correct Answer: B
Rationale: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.