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The client is diagnosed with cancer of the head of the pancreas. Which signs and symptoms should the nurse expect to assess?
- A. Clay-colored stools and dark urine.
- B. Night sweats and fever.
- C. Left lower abdominal cramps and tenesmus.
- D. Nausea and coffee-ground emesis.
Correct Answer: A
Rationale: Cancer in the head of the pancreas obstructs the bile duct, causing clay-colored stools and dark urine from jaundice. Night sweats, cramps, and coffee-ground emesis are less specific.
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Which sign/symptom indicates to the nurse the client is experiencing hypoparathyroidism?
- A. A negative Trousseau's sign.
- B. A positive Chvostek's sign.
- C. Nocturnal muscle cramps.
- D. Tented skin turgor.
Correct Answer: B
Rationale: A positive Chvostek’s sign (facial twitching) indicates hypocalcemia from hypoparathyroidism. Negative Trousseau’s, cramps, and turgor are less specific.
The nurse determined that the client's fluid volume deficit from HHNS has resolved. Which serum laboratory finding led to the nurse's conclusion?
- A. Decreased glucose
- B. Decreased sodium
- C. Decreased osmolality
- D. Decreased potassium
Correct Answer: C
Rationale: A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving.
Which I.V. medication can the nurse expect the physician to order to treat the client's condition?
- A. Calcium gluconate
- B. Ferrous sulfate
- C. Potassium chloride
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Calcium gluconate is used to treat tetany caused by hypocalcemia in hypoparathyroidism.
The nurse is admitting a client to rule out aldosteronism. Which assessment data support the client's diagnosis?
- A. Temperature.
- B. Pulse.
- C. Respirations.
- D. Blood pressure.
Correct Answer: D
Rationale: Elevated blood pressure is a hallmark of aldosteronism due to sodium retention and fluid overload. Temperature, pulse, and respirations are less specific.
Which nursing intervention is essential for monitoring the client's condition?
- A. Measuring intake and output
- B. Muxying blood glucose levels
- C. Inserting a Foley catheter
- D. Sending urine samples to the laboratory
Correct Answer: A
Rationale: Monitoring intake and output is critical in diabetes insipidus to assess fluid balance and the severity of polyuria.