Nokea
A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to the nursing assistant?
- A. Remind patient to change positions slowly.
- B. Check the patient for muscle weakness.
- C. Teach the patient how to collect 24-hour urine.
- D. Plan nursing interventions to promote fluid balance.
Correct Answer: A
Rationale: Reminding the patient to change positions slowly is a non-invasive task that is appropriate for delegation to a nursing assistant, as it helps prevent dizziness or hypotension due to adrenocortical insufficiency.
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Which of the following is least associated with the adrenal medulla?
- A. Catecholamines
- B. Epinephrine and norepinephrine
- C. Fight-or-flight response
- D. Sugar, salt, and sex
Correct Answer: D
Rationale: The correct answer is D because the adrenal medulla is primarily involved in the production of catecholamines, specifically epinephrine and norepinephrine, which are associated with the fight-or-flight response. This response is triggered by stress and prepares the body for action by increasing heart rate, dilating airways, and redirecting blood flow. On the other hand, the regulation of sugar, salt, and sex hormones is mainly controlled by the adrenal cortex, not the adrenal medulla. Therefore, while choices A, B, and C are directly related to the adrenal medulla's function, choice D is least associated with it.
Delegation Decision: The following interventions are planned for a diabetic patient. Which intervention can the nurse delegate to unlicensed assistive personnel (UAP)?
- A. Discuss complications of diabetes.
- B. Check that the bath water is not too hot.
- C. Check the patient's technique for drawing up insulin.
- D. Teach the patient to use a meter for self-monitoring of blood glucose.
Correct Answer: B
Rationale: The UAP can check the bath water temperature, but teaching and assessing insulin-related skills require nursing knowledge.
Diabetes insipidus is caused due to deficiency of hormone:
- A. Insulin
- B. ADH
- C. Growth hormone
- D. Oxytocin
Correct Answer: B
Rationale: The correct answer is B: ADH (antidiuretic hormone). Diabetes insipidus is a condition characterized by excessive thirst and urination due to a deficiency of ADH, which regulates water balance in the body. Insulin (choice A) is related to diabetes mellitus, not diabetes insipidus. Growth hormone (choice C) and oxytocin (choice D) do not play a direct role in water balance regulation. Therefore, choice B is the most appropriate answer for this question.
The patient with type 1 diabetes mellitus is in the clinic to check his long-term glycemic control. Which test should be used?
- A. Water deprivation test
- B. Fasting blood glucose test
- C. Oral glucose tolerance test
- D. Glycosylated hemoglobin (A1C)
Correct Answer: D
Rationale: The A1C test measures long-term glycemic control and is the most appropriate test for monitoring type 1 diabetes mellitus.
Complete the following sentence: Antidiuretic hormone is secreted from the…
- A. Adrenal cortex
- B. Thyroid gland
- C. Pancreas
- D. Posterior pituitary gland
Correct Answer: D
Rationale: The correct answer is D: Posterior pituitary gland. Antidiuretic hormone (ADH), also known as vasopressin, is produced in the hypothalamus and then transported to the posterior pituitary gland for secretion into the bloodstream. ADH plays a key role in regulating water balance by controlling the reabsorption of water in the kidneys. Choices A, B, and C are incorrect as they are not the primary sites of ADH production and secretion. The adrenal cortex produces hormones like cortisol and aldosterone, the thyroid gland produces hormones like thyroxine, and the pancreas produces insulin and glucagon.