Nokea
The client is ready for discharge following an adrenalectomy. Which statement that the client makes indicates the best understanding of the client's condition?
- A. I will continue on a low-sodium, low-potassium diet.'
- B. My husband has arranged for a marriage counselor because of our fights.'
- C. I will stay out of the sun so I will not turn splotchy brown.'
- D. I will take all of those pills every day.'
Correct Answer: D
Rationale: Lifelong steroid replacement is required post-adrenalectomy, and taking prescribed pills daily shows understanding. A high-sodium, low-potassium diet is needed, and photosensitivity is not an issue.
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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.
The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client?
- A. Explain it will take up to a month for symptoms of hyperthyroidism to subside.
- B. Teach the iodine therapy will have to be tapered slowly over one (1) week.
- C. Discuss the client will have to be hospitalized during the radioactive therapy.
- D. Inform the client after therapy the client will not have to take any medication.
Correct Answer: A
Rationale: Radioactive iodine takes weeks to reduce hyperthyroid symptoms, requiring client understanding. Tapering, hospitalization, and stopping medications are incorrect.
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.
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
- A. Glucose.
- B. Potassium.
- C. Calcium.
- D. Sodium.
Correct Answer: B
Rationale: DKA causes potassium depletion due to acidosis and diuresis; replacement is anticipated to prevent arrhythmias. Glucose is not an electrolyte, and calcium/sodium are less critical.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which intervention should the nurse delegate to the UAP?
- A. Assist the client with abdominal pain to turn to the side and flex the knees.
- B. Monitor the Jackson Pratt drainage tube to ensure it is draining properly.
- C. Check to see if the client is sleeping after pain medication is administered.
- D. Empty the bedside commode of the client who has been having melena.
Correct Answer: A
Rationale: Assisting with positioning is within the UAP’s scope and promotes comfort. Monitoring drains, assessing sleep, and handling melena require RN skills.