Nokea
The nurse caring for a 75-year-old man who has developed diabetes insipidus following a head injury expects to see which aspect emphasized in the plan of care?
- A. limiting fluids to 1500 mL a day.
- B. encouraging physical exercise.
- C. protecting patient from injury.
- D. discouraging daytime naps.
Correct Answer: C
Rationale: The patients need protection from injury because they are often exhausted from sleep deprivation and having to get up frequently at night. Fluids should not be limited and their energy should be preserved.
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The nurse would instruct a patient with hypocalcemia from hypoparathyroidism about a diet that should include which item?
- A. high phosphorus foods.
- B. canned fish with the bones.
- C. cucumbers.
- D. tofu.
- E. bananas.
- F. Tomatoes
Correct Answer: B,C,D,F
Rationale: The hypocalcemic patient should eat a high-calcium, low-phosphorus diet that includes canned fish, cucumbers, tofu, and tomatoes as an aid to the absorption of the calcium.
A patient with a history of Graves' disease is admitted to the unit with shortness of breath. The nurse notes the patient's vital signs: T 103°F, P 160, R 24, BP 160/80. The nurse also notes distended neck veins. Which disorder does the patient most likely have?
- A. Pulmonary embolism
- B. Hypertensive crisis
- C. Thyroid storm
- D. Cushing crisis
Correct Answer: C
Rationale: In a thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. Additionally, the patient may develop nausea, vomiting, severe tachycardia, severe hypertension, and occasionally hyperthermia up to 41°C (106°F). Extreme restlessness, cardiac arrhythmia, and delirium may also occur. The patient may develop heart failure and may die.
In which manner will the nurse administer insulin to prevent lipohypertrophy?
- A. At room temperature
- B. At body temperature
- C. Straight from the refrigerator
- D. After rolling bottle between hands to warm
Correct Answer: A
Rationale: In fact, it is now believed that insulin should be administered at room temperature, not straight from the refrigerator, to help prevent insulin lipohypertrophy.
As the nurse is shaving a patient who is 2 days postoperative from a thyroidectomy, the patient has a spasm of the facial muscles. The nurse will recognize this as which sign?
- A. Chvostek sign
- B. Montgomery sign
- C. Trousseau sign
- D. Homans' sign
Correct Answer: A
Rationale: The spasm of facial muscles when stimulated is the Chvostek sign, an indication of hypocalcemic tetany.
Which condition does the Chvostek sign and the Trousseau sign indicate?
- A. Low levels of serum calcium
- B. High levels of blood sugar
- C. Low levels of serum sodium
- D. High levels of serum aldosterone
Correct Answer: A
Rationale: Low levels of blood calcium may cause the Chvostek sign and Trousseau sign.