Nokea
A woman with a tumor of the adrenal cortex says to the nurse, 'Will I always look this ugly? I hate having a beard.' What is the best response for the nurse to make?
- A. After surgery, you will not develop any more symptoms, but the changes you have now will linger.'
- B. That varies from person to person. You should ask your physician.'
- C. After surgery, your appearance should gradually return to normal.'
- D. Electrolysis and plastic surgery should make your appearance normal.'
Correct Answer: C
Rationale: Post-adrenalectomy, hormonal imbalances causing symptoms like hirsutism should resolve, gradually normalizing appearance.
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The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention?
- A. Administer the insulin that is due now.
- B. Call the lab for a STAT serum glucose level.
- C. Have the client choose foods for a meal now.
- D. Provide juice with 15 grams of carbohydrates.
Correct Answer: D
Rationale: Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of 'altered nutrition: less than body requirements.' Which collaborative intervention should the nurse include in the plan of care?
- A. Continuous feedings via (PEG) tube.
- B. Have the family bring in foods from home.
- C. Assess for food preferences.
- D. Refer to the dietitian.
Correct Answer: D
Rationale: Referring to a dietitian ensures specialized nutritional planning for pancreatic cancer, addressing malabsorption and weight loss. PEG feedings, family foods, and preferences are secondary.
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus?
- A. Serum sodium.
- B. Serum calcium.
- C. Urine glucose.
- D. Urine white blood cells.
Correct Answer: A
Rationale: Diabetes insipidus causes dilute urine, risking hypernatremia; serum sodium monitoring is critical. Calcium, urine glucose, and WBCs are unrelated.
Because propylthiouracil (Propyl-Thyracil) can cause agranulocytosis, the nurse advises the client to notify the physician's health problem occurs?
- A. Persistent sore throat
- B. Occasional heart palpitations
- C. Fatigue on exertion
- D. Prolonged bleeding with trauma
Correct Answer: A
Rationale: Agranulocytosis, a side effect of propylthiouracil, can manifest as a persistent sore throat due to decreased white blood cells.
The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply.
- A. Restrict fluids per health-care provider order.
- B. Assess level of consciousness every two (2) hours.
- C. Provide an atmosphere of stimulation.
- D. Monitor urine and serum osmolality.
- E. Weigh the client every three (3) days.
Correct Answer: A,B,D
Rationale: Fluid restriction, frequent consciousness checks, and osmolality monitoring manage SIADH’s hyponatremia and fluid overload. Stimulation is inappropriate, and weighing every 3 days is too infrequent.