Nokea
The nurse assesses the client following a total thyroidectomy. Which finding indicates that the client has a positive Trousseau's sign?
- A. Illustration 1: Carpal spasm
- B. Illustration 2: Cheek twitching
- C. Illustration 3: Thyroid palpation
- D. Illustration 4: Red reflex
Correct Answer: A
Rationale: Trousseau's sign is carpal spasm due to hypocalcemia from parathyroid gland injury during thyroidectomy.
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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.
Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment?
- A. The client has tented skin turgor and dry mucous membranes.
- B. The client is alert and oriented to date, time, and place.
- C. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15.
- D. The client's serum potassium level is 3.3 mEq/L.
Correct Answer: B
Rationale: Alertness and orientation indicate resolving DKA, as cerebral function improves. Persistent dehydration, acidosis (pH 7.29), and hypokalemia are not signs of improvement.
The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of 'risk for altered skin integrity related to pruritus.' Which intervention should the nurse implement?
- A. Assess tissue turgor.
- B. Apply antifungal creams.
- C. Monitor bony prominences for breakdown.
- D. Have the client keep the fingernails short.
Correct Answer: D
Rationale: Short fingernails prevent scratching from pruritus (due to jaundice), reducing skin breakdown risk. Turgor, antifungal creams, and bony prominences are unrelated.
Because propylthiouracil (Propyl-Thyracil) can cause agranulocytosis, the nurse advises the client to notify the physician's health problem occurs?
- A. Persistent sore throat
- B. Occasional heart palpitations
- C. Fatigue on exertion
- D. Prolonged bleeding with trauma
Correct Answer: A
Rationale: Agranulocytosis, a side effect of propylthiouracil, can manifest as a persistent sore throat due to decreased white blood cells.