Nokea
The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective?
- A. The client has a three (3)-pound weight gain.
- B. The client has a decreased pulse rate.
- C. The client's temperature is WNL.
- D. The client denies any diaphoresis.
Correct Answer: C
Rationale: Normal temperature indicates corrected hypothermia from hypothyroidism. Weight gain, decreased pulse, and no diaphoresis are not specific indicators.
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To detect complications of surgery in the immediate postoperative period, which assessment component is most important for the nurse to monitor?
- A. Blood pressure
- B. Urine output
- C. Upperness
- D. Specific gravity
Correct Answer: A
Rationale: Blood pressure monitoring detects adrenal insufficiency or bleeding post-adrenalectomy.
Which signs/symptoms should the nurse expect to assess in the client diagnosed with an insulinoma?
- A. Nervousness, jitteriness, and diaphoresis.
- B. Flushed skin, dry mouth, and tented skin turgor.
- C. Polyuria, polydipsia, and polyphagia.
- D. Hypertension, tachycardia, and feeling hot.
Correct Answer: A
Rationale: An insulinoma is a pancreatic tumor causing excessive insulin secretion, leading to hypoglycemia. Symptoms include nervousness, jitteriness, and diaphoresis (Whipple’s triad). Flushed skin and dehydration suggest hyperglycemia, polyuria/polydipsia/polyphagia are diabetes symptoms, and hypertension/tachycardia are more typical of pheochromocytoma.
The nurse observes the client self-administering the medication. Which action indicates that the client is using the medication correctly?
- A. The client shakes the medication vigorously
- B. The client's head is tilted to the side.
- C. The client inverts the drug container.
- D. The client inhales with each spray.
Correct Answer: D
Rationale: For intranasal lypressin, inhaling with each spray ensures proper delivery of the medication to the nasal mucosa.
The nurse observes a colleague caring for the client who had a hypophysectomy via the transsphenoidal approach 12 hours ago. Which action would require the observing nurse to intervene?
- A. Elevates the head of the client's bed to 30 degrees
- B. Gathers supplies to replace the bloody nasal packing
- C. Moisturizes the client's oral mucous membranes
- D. Places a cold washcloth over the client's swollen eyes
Correct Answer: B
Rationale: Nasal packing is left in place for 3-4 days post-hypophysectomy and should not be changed without an HCP order.
The client is diagnosed with hypothyroidism. Which assessment data support this diagnosis?
- A. The client's vital signs are: T 99.0, P 110, R 26, and BP 145/80.
- B. The client complains of constipation and being constantly cold.
- C. The client has an intake of 780 mL and output of 256 mL.
- D. The client complains of a headache and has projectile vomiting.
Correct Answer: B
Rationale: Constipation and cold intolerance are classic hypothyroidism symptoms due to slowed metabolism. Tachycardia/hypertension, fluid imbalance, and vomiting are unrelated.