Nokea
Post thyroidectomy the nurse assesses for complications by performing which of the following assessments?
- A. Accu-Chek
- B. Chvostek's
- C. Ballottement
- D. Ice water colonic
Correct Answer: B
Rationale: The correct answer is Chvostek's. A positive Chvostek's and Trousseau's sign is indicative of tetany, which is associated with low calcium levels. This can occur if parathyroid glands are accidentally removed during thyroidectomy. Accu-Chek is a brand of blood glucose monitor used for checking blood sugar levels and is not relevant in this context. Ballottement is a technique used in physical examination to assess for fluid in the body, typically in the abdomen or joints. Ice water colonic is not a standard medical assessment and is not relevant to post-thyroidectomy complications.
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On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?
- A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
- B. Hold medications and notify the physician
- C. Arouse the client and give some orange juice with sugar packets added
- D. Give the medications as ordered and re-check blood sugar in one hour
Correct Answer: A
Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.
Because of the possible nervous system side-effects that occur with isoniazid (Nydrazid) therapy, which supplementary nutritional agent would the nurse teach the client to take as a prophylaxis?
- A. Alpha tocopherol (vitamin E)
- B. Ascorbic acid (vitamin C)
- C. Calcitriol (vitamin D)
- D. Pyridoxine (vitamin B6)
Correct Answer: D
Rationale: Pyridoxine is the correct choice in this scenario because it is used as a prophylaxis to prevent neuritis, a possible nervous system side-effect of isoniazid therapy. Neuritis is a condition that involves inflammation of the nerves and can be a side effect of isoniazid. Pyridoxine, also known as vitamin B6, helps prevent this side effect. Vitamin E (Alpha tocopherol), vitamin C (Ascorbic acid), and vitamin D (Calcitriol) do not specifically address the nervous system side-effects associated with isoniazid therapy, making them incorrect choices.
Which symptom is the client who self-administered an overdose of acetaminophen most likely to exhibit?
- A. Pink frothy sputum
- B. Seizure activity
- C. Jaundiced conjunctiva
- D. Diaphoresis and fever
Correct Answer: C
Rationale: When a client self-administers an overdose of acetaminophen, the liver is primarily affected. Jaundiced conjunctiva, which is yellowing of the eyes, is a common symptom of liver damage. Pink frothy sputum is typically associated with conditions like pulmonary edema, not acetaminophen overdose. Seizure activity is not a common symptom of acetaminophen overdose but can be seen in other toxicities. Diaphoresis and fever are more generalized symptoms and not specific to acetaminophen overdose.
A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DKA). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones. Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis. Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction. Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis. Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.
The client with chronic pancreatitis should be taught how to monitor for which of the following possible additional problems associated with pancreatic disease?
- A. Hypertension
- B. Diabetes
- C. Hypothyroidism
- D. Graves' disease
Correct Answer: B
Rationale: The correct answer is diabetes. In chronic pancreatitis, the pancreas may become unable to produce sufficient insulin, leading to diabetes. This connection underscores the importance of monitoring blood sugar levels and understanding the signs and symptoms of diabetes in clients with chronic pancreatitis.
Choice A, hypertension, is not directly associated with pancreatic disease but rather with cardiovascular health. Choice C, hypothyroidism, and Choice D, Graves' disease, are unrelated to pancreatic disease and are endocrine disorders affecting the thyroid gland.