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An adult is admitted to the hospital with a diagnosis of hypothyroidism. Which findings would the nurse most likely elicit during the nursing assessment?
- A. Elevated blood pressure and temperature
- B. Tachycardia and weight gain
- C. Hypothermia and constipation
- D. Moist skin and coarse hair
Correct Answer: C
Rationale: Hypothyroidism causes hypothermia and constipation due to slowed metabolism, unlike the other symptoms.
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The nurse is discussing discharge plans with a client who had a transsphenoidal hypophysectomy. Which statement made by the client indicates a need for more teaching?
- A. I won't brush my teeth until the doctor removes the stitches.'
- B. I will wear loafers instead of tie shoes.'
- C. Where can I get a Medic-Alert bracelet?'
- D. I will take all these new medicines until I feel better.'
Correct Answer: D
Rationale: Stopping medications when feeling better indicates a lack of understanding, as lifelong hormone replacement is often required post-hypophysectomy.
The nurse is admitting the client tentatively diagnosed with possible hyperaldosteronism. What should be the nurse's priority?
- A. Prepare for a computed tomography (CT) scan
- B. Give prn prescribed analgesic to treat headache
- C. Obtain an ECG to evaluate for dysrhythmias
- D. Assess for generalized weakness and fatigue
Correct Answer: C
Rationale: Obtaining an ECG is priority to detect dysrhythmias from hypokalemia caused by potassium wasting in hyperaldosteronism.
The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
- A. Serum blood glucose level of 74 mg/dL.
- B. Pulse oximeter reading of 90%.
- C. Telemetry reading showing sinus bradycardia.
- D. The client is lethargic and sleeps all the time.
Correct Answer: B
Rationale: A pulse oximetry of 90% indicates hypoxia, requiring immediate intervention in myxedema coma. Normal glucose, bradycardia, and lethargy are expected.
Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?
- A. Excessive thirst.
- B. Orthopnea.
- C. Ascites.
- D. Concentrated urine output.
Correct Answer: D
Rationale: SIADH causes excessive ADH, leading to water retention, hyponatremia, and concentrated urine output due to reduced urine volume. Excessive thirst is typical of diabetes insipidus, orthopnea relates to heart failure, and ascites is linked to liver disease.
The home health nurse is admitting a client diagnosed with cancer of the pancreas. Which information is the most important for the nurse to discuss with the client?
- A. Determine the client's food preferences.
- B. Ask the client if there is an advance directive.
- C. Find out about insurance/Medicare reimbursement.
- D. Explain the client should eat as much as possible.
Correct Answer: B
Rationale: An advance directive is critical for pancreatic cancer due to poor prognosis, ensuring the client’s wishes are respected. Food preferences, insurance, and eating are secondary.