Nokea
The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement?
- A. Assess for dehydration and monitor blood glucose levels.
- B. Assess for nausea and vomiting and weigh daily.
- C. Monitor potassium levels and encourage fluid intake.
- D. Administer vasopressin IV and conduct a fluid deprivation test.
Correct Answer: B
Rationale: Nausea/vomiting and daily weights monitor SIADH complications (e.g., hyponatremia, fluid overload). Dehydration is unlikely, potassium is less critical, and vasopressin worsens SIADH.
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A clinic nurse is teaching the client newly diagnosed with hypothyroidism. Which instructions should the nurse provide about taking levothyroxine sodium? Select all that apply.
- A. Take the medication 1 hour before or 2 hours after breakfast.
- B. Call the clinic if the pulse before taking the medication is greater than 100 beats per minute.
- C. Report adverse drug effects, including weight gain, cold intolerance, and alopecia.
- D. Take this drug as prescribed; it replaces thyroid hormone thatå‚¾å‘ diminished or absent.
- E. Have frequent laboratory monitoring to be sure your levels of T3 and T4 decrease.
Correct Answer: A,B,D
Rationale: Taking levothyroxine on an empty stomach ensures absorption, notifying the clinic for tachycardia prevents overdose, and taking it as prescribed replaces deficient hormone.
The client diagnosed with acute pancreatitis is being discharged home. Which statement by the client indicates the teaching has been effective?
- A. I should decrease my intake of coffee, tea, and cola.
- B. I will eat a low-fat diet and avoid spicy foods.
- C. I will check my amylase and lipase levels daily.
- D. I will return to work tomorrow but take it easy.
Correct Answer: B
Rationale: A low-fat, non-spicy diet prevents pancreatitis exacerbation, indicating effective teaching. Caffeine reduction is secondary, amylase/lipase are not self-monitored, and early work return is risky.
What should be included in the nursing care plan for a client with diabetes insipidus?
- A. Blood pressure every hour
- B. Strict intake and output
- C. Urine for ketone bodies
- D. Glucose monitoring four times a day
Correct Answer: B
Rationale: Diabetes insipidus causes excessive urine output due to low antidiuretic hormone, requiring strict intake and output monitoring to assess fluid balance.
The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included?
- A. Administer steroid medications.
- B. Place the client on fluid restriction.
- C. Provide frequent stimulation.
- D. Consult physical therapy for gait training.
Correct Answer: A
Rationale: Steroid replacement (e.g., hydrocortisone) is essential for Addison’s to replace deficient cortisol/aldosterone. Fluid restriction, stimulation, and gait training are inappropriate.
A friend brings the older adult homeless client to a free health screening clinic. The friend is unable to continue administering the client's morning and evening insulin dose for treating type 1 DM. When advocating for this client, which action by the nurse is most appropriate?
- A. Notify Adult Protective Services about the client's condition and living situation.
- B. Ask where the client lives and whether someone else could administer the insulin.
- C. Arrange with a local homeless shelter to have someone give the insulin injections.
- D. Have the client return to the screening clinic morning and evening to receive the injections.
Correct Answer: C
Rationale: The nurse advocates by ensuring that the client has access to health care services. The nurse should contact a social worker whose role it is to make placement arrangements.