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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.
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The nurse is administering morning medications. Which medications should the nurse administer question?
- A. The oral carafate to a client who has not eaten breakfast.
- B. The subcutaneous insulin to a client refusing blood glucose checks.
- C. The levothyroxine PO to a client diagnosed with hypothyroidism.
- D. The sliding scale insulin to a client whose blood glucose level is 320 mg/dL.
Correct Answer: B
Rationale: Insulin without glucose checks risks hypoglycemia, requiring clarification. Carafate timing, levothyroxine, and sliding-scale insulin are appropriate.
What is the best way to assess for hemorrhage in a client who has had a thyroidectomy?
- A. Check the pulse and blood pressure hourly.
- B. Roll the client to the side and check for evidence of bleeding.
- C. Ask the client if he/she feels blood trickling down the back of the throat.
- D. Place a hand under the client's neck and shoulders to feel bed linens.
Correct Answer: D
Rationale: Placing a hand under the neck and shoulders detects blood pooling under the incision, a common site for post-thyroidectomy hemorrhage.
The nurse is teaching a community class to people with type 2 diabetes mellitus. Which explanation explains the development of type 2 diabetes?
- A. The islet cells in the pancreas stop producing insulin.
- B. The client eats too many foods high in sugar.
- C. The pituitary gland does not produce vasopressin.
- D. The cells become resistant to the circulating insulin.
Correct Answer: D
Rationale: Type 2 diabetes develops due to insulin resistance, where cells fail to respond to insulin. Islet cell failure is type 1, sugar intake is a risk, and vasopressin is unrelated.
Which response by the nurse about potassium iodide (Lugol's solution) is correct?
- A. It firms the gland so it is easily removed.
- B. It decreases the postoperative recovery time.
- C. It decreases the risk of postoperative bleeding.
- D. It eliminates the need for hormone replacement.
Correct Answer: C
Rationale: Potassium iodide reduces thyroid vascularity, decreasing the risk of postoperative bleeding.
The nurse is assessing a client in an outpatient clinic. Which assessment data are a risk factor for developing pheochromocytoma?
- A. A history of skin cancer.
- B. A history of high blood pressure.
- C. A family history of adrenal tumors.
- D. A family history of migraine headaches.
Correct Answer: C
Rationale: A family history of adrenal tumors increases pheochromocytoma risk, as it’s a catecholamine-secreting adrenal tumor. Skin cancer, hypertension, and migraines are unrelated.