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The client diagnosed with diabetes complains of a curtain being drawn across the eyes. Which should the nurse implement first?
- A. Assess the eyes using an ophthalmoscope.
- B. Tell the client to keep the eyes closed.
- C. Notify the health-care provider (HCP).
- D. Call the Rapid Response Team (RRT).
Correct Answer: C
Rationale: A curtain-like vision loss suggests retinal detachment, a diabetic complication requiring urgent HCP notification. Ophthalmoscopy, closing eyes, or RRT are inappropriate first steps.
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The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client?
- A. Refer the client to the American Diabetes Association.
- B. Do not take any over-the-counter (OTC) medications.
- C. Take the prescribed insulin even when unable to eat because of illness.
- D. Explain the need to get the annual flu and pneumonia vaccines.
Correct Answer: C
Rationale: Continuing insulin during illness prevents DKA by maintaining glucose control. ADA referral, avoiding OTC meds, and vaccines are secondary.
A client has a transsphenoidal hypophysectomy to remove a pituitary tumor. When the client returns to the nursing unit following surgery, the head of the bed is elevated 30 degrees. What is the primary purpose for placing the client in this position?
- A. To promote respiratory effort
- B. To reduce pressure on the sella turcica
- C. To prevent acidosis
- D. To promote oxygenation
Correct Answer: B
Rationale: Elevating the head 30 degrees reduces pressure on the sella turcica, minimizing the risk of cerebrospinal fluid leakage post-hypophysectomy.
The nurse is caring for clients on a medical floor. Which client should be assessed first?
- A. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday.
- B. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours.
- C. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching.
- D. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.
Correct Answer: C
Rationale: Muscle twitching in SIADH suggests hyponatremia-induced neurological symptoms, requiring immediate assessment. Weight gain, slight DI output imbalance, and tiredness are less urgent.
Which is the best explanation by the nurse concerning an effect of hyperparathyroidism?
- A. The inability to maintain balance
- B. The risk of developing seizures
- C. Fainting when changing positions
- D. Pathologic bone fractures
Correct Answer: D
Rationale: Hyperparathyroidism weakens bones due to calcium loss, increasing the risk of pathologic fractures.
The client is three (3) days postoperative unilateral adrenalectomy. Which discharge instructions should the nurse teach?
- A. Discuss the need for lifelong steroid replacement.
- B. Instruct the client on administration of vasopressin.
- C. Teach the client to care for the suprapubic Foley catheter.
- D. Tell the client to notify the HCP if the incision is inflamed.
Correct Answer: D
Rationale: Notifying the HCP for incision inflammation prevents infection post-adrenalectomy. Lifelong steroids are for bilateral procedures, vasopressin is for DI, and Foley catheters are not standard.