Nokea
The client taking thyroid replacement hormone is hospitalized, and a thyroid replacement hormone is not prescribed. A week after being hospitalized, the nurse assesses that the client is becoming increasingly lethargic and has a decreased blood pressure, respiratory rate, temperature, and pulse. Which actions should be taken by the nurse? Place each nursing action in the order of priority.
- A. Warm the client
- B. Administer intravenous fluids
- C. Assist in ventilatory support
- D. Administer thyroxine as prescribed
Correct Answer: C,B,A,D
Rationale: Ventilatory support addresses decreased respiratory rate, IV fluids treat hypotension, warming prevents metabolic demand increase, and thyroxine corrects hypothyroidism.
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The nurse is teaching a client to self-administer insulin. The instructions should include teaching the client to:
- A. inject the needle at a 90-degree angle into the muscle.
- B. vigorously massage the area after injecting the insulin.
- C. rotate injection sites.
- D. keep the open bottle of insulin in the refrigerator.
Correct Answer: C
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption. Insulin is injected subcutaneously, not into muscle, and massaging can alter absorption.
The nurse is discussing the endocrine system with the client. Which endocrine gland secretes epinephrine and norepinephrine?
- A. The pancreas.
- B. The adrenal cortex.
- C. The adrenal medulla.
- D. The anterior pituitary gland.
Correct Answer: C
Rationale: The adrenal medulla secretes catecholamines (epinephrine and norepinephrine), which regulate the fight-or-flight response. The pancreas secretes insulin/glucagon, the adrenal cortex produces corticosteroids, and the anterior pituitary releases hormones like ACTH.
Before administering this medication, what is essential for the nurse to ask the client?
- A. Do you have trouble swallowing?
- B. Do you keep the child form of medication?
- C. Have you had digestive disorders in the past?
- D. Is there a possibility you could be pregnant?
Correct Answer: D
Rationale: Propylthiouracil is contraindicated in pregnancy due to potential teratogenic effects.
What must the nurse do when preparing a client for a computed tomography (CT) scan?
- A. Administer a laxative prep
- B. Encourage fluids
- C. Explain the procedure
- D. Administer a radioisotope
Correct Answer: C
Rationale: Explaining the procedure reduces anxiety and ensures cooperation. A CT scan may involve iodine dye, so checking for allergies (e.g., shellfish) is also important, but explanation is primary.
Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?
- A. Excessive thirst.
- B. Orthopnea.
- C. Ascites.
- D. Concentrated urine output.
Correct Answer: D
Rationale: SIADH causes excessive ADH, leading to water retention, hyponatremia, and concentrated urine output due to reduced urine volume. Excessive thirst is typical of diabetes insipidus, orthopnea relates to heart failure, and ascites is linked to liver disease.