Nokea
The concepts of nutrition and metabolism have been identified for the client. Which referral should the nurse include in the plan of care?
- A. Physical therapy.
- B. Social work.
- C. Speech therapy.
- D. Dietary.
Correct Answer: D
Rationale: A dietary referral addresses nutrition and metabolism, optimizing dietary management for conditions like diabetes. Other referrals are unrelated.
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Which monitoring approach is best for the nurse to recommend?
- A. Using the urine with a chemical reagent strip
- B. Using a glucometer to check capillary blood glucose levels
- C. Having laboratory personnel draw venous blood samples
- D. Arranging for testing by a home health agency nurse
Correct Answer: B
Rationale: A glucometer provides accurate, real-time blood glucose levels for effective diabetes management.
Which question should the nurse ask when assessing the client for an endocrine dysfunction?
- A. Have you noticed any pain in your legs when walking?
- B. Have you had any unexplained weight loss?
- C. Have you noticed any change in your bowel movements?
- D. Have you experienced any joint pain or discomfort?
Correct Answer: B
Rationale: Unexplained weight loss is a hallmark symptom of endocrine disorders like hyperthyroidism or diabetes mellitus, making it a key assessment question. Leg pain relates to vascular issues, bowel changes are less specific, and joint pain is more musculoskeletal.
Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information?
- A. Antibiotics will help to prevent respiratory complications following surgery.
- B. Meningitis is a complication following transsphenoidal hypophysectomy.
- C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
- D. Hormone replacement is essential after hypophysectomy.
Correct Answer: B
Rationale: The transsphenoidal approach through the mouth increases the risk of meningitis due to oral bacteria, necessitating prophylactic antibiotics.
The client is a 62-year-old woman who is 30 pounds overweight. She comes to the doctor's office complaining of headaches, frequent hunger, excessive thirst, and urination. The presenting complaints suggest that the nurse should assess for other signs of which condition?
- A. Hypothyroidism
- B. Acute pyelonephritis
- C. Addison's disease
- D. Diabetes mellitus
Correct Answer: D
Rationale: Headaches, polyphagia, polydipsia, and polyuria are classic symptoms of diabetes mellitus, especially in an overweight individual.
Which nursing diagnosis should the nursing team consider when developing this client's care plan?
- A. Activity intolerance
- B. Self-care deficit
- C. Ineffective breathing
- D. Impaired swallowing
Correct Answer: B
Rationale: Acromegaly can cause joint pain and muscle weakness, contributing to self-care deficits.