Nokea
Nurse Troy is aware that the most appropriate nursing diagnosis for a client with Addison's disease is:
- A. Risk for infection
- B. Excessive fluid volume
- C. Urinary retention
- D. Hypothermia
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for a client with Addison's disease is 'Risk for infection.' Addison's disease is characterized by corticosteroid deficiency, which leads to immune suppression, making these clients more susceptible to infections. This diagnosis reflects the increased vulnerability of clients with Addison's disease to infections. Choices B, C, and D are incorrect because Addison's disease does not typically present with excessive fluid volume, urinary retention, or hypothermia as primary concerns.
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A nurse manager is reviewing the nurse's documentation on the unit. Which of the following best describes the importance of this review?
- A. The nurse manager's review of documentation is crucial to ensure that it meets legal and ethical standards and accurately reflects the care provided to patients.
- B. The nurse manager's review of documentation is important to ensure that it is thorough, accurate, and reflects the nurse's accountability for patient care.
- C. The nurse manager's review of documentation is necessary to ensure that it is consistent with the unit's policies and procedures and that it accurately reflects the care provided.
- D. The nurse manager's review of documentation is essential to ensure that it meets regulatory requirements and that it supports the delivery of safe and effective patient care.
Correct Answer: D
Rationale: The nurse manager's review of documentation is a critical aspect of maintaining quality patient care. Choice D is the correct answer as it highlights the importance of ensuring that documentation meets regulatory requirements, supporting the delivery of safe and effective patient care. Regulatory requirements are established to ensure that healthcare facilities function within established guidelines and standards, promoting patient safety and quality of care. Choices A, B, and C, although important aspects of documentation review, do not fully encapsulate the significant role of regulatory compliance in ensuring the overall quality and safety of patient care.
A client with hyperparathyroidism is receiving dietary instructions. Which of the following foods should the client avoid?
- A. Milk
- B. Bananas
- C. Spinach
- D. Processed meats
Correct Answer: A
Rationale: In hyperparathyroidism, there are already elevated calcium levels in the body. Therefore, clients should avoid high-calcium foods like milk to prevent further increase in calcium levels. Bananas, spinach, and processed meats do not have significant calcium content and do not need to be avoided specifically in hyperparathyroidism.
The nurse is caring for a client with primary adrenal insufficiency (Addison's disease). Which of the following laboratory findings would the nurse expect?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Hypercalcemia
Correct Answer: B
Rationale: In primary adrenal insufficiency (Addison's disease), there is a decrease in aldosterone levels, leading to sodium loss and potassium retention. This imbalance results in hyperkalemia, making choice B the correct answer. Hypernatremia (choice A) is unlikely due to sodium loss. Hyperglycemia (choice C) and hypercalcemia (choice D) are not typically associated with primary adrenal insufficiency.
The healthcare provider is assessing a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory findings is most consistent with this condition?
- A. Increased serum sodium
- B. Decreased urine specific gravity
- C. Decreased serum osmolality
- D. Increased serum potassium
Correct Answer: C
Rationale: The correct answer is C: Decreased serum osmolality. Syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by the excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. The dilution of sodium results in decreased serum osmolality. Option A is incorrect because SIADH causes hyponatremia, resulting in decreased serum sodium levels. Option B is incorrect because SIADH leads to concentrated urine with increased urine specific gravity. Option D is incorrect as SIADH does not typically affect serum potassium levels.
Nurse Kate is providing dietary instructions to a male client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:
- A. Increasing saturated fat intake and fasting in the afternoon
- B. Increasing intake of vitamins B and D and taking iron supplements
- C. Eating a candy bar if lightheadedness occurs
- D. Consuming a low-carbohydrate, high-protein diet and avoiding fasting
Correct Answer: D
Rationale: A low-carbohydrate, high-protein diet is beneficial for individuals with hypoglycemia as it helps in maintaining stable blood sugar levels. Choice A is incorrect as increasing saturated fat intake and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron supplements do not directly address hypoglycemia. Choice C is incorrect as consuming a candy bar may provide temporary relief but does not address the underlying cause of hypoglycemia.