Nokea
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.
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The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?
- A. Complaints of extreme fatigue and hair loss.
- B. Exophthalmos and complaints of nervousness.
- C. Complaints of profuse sweating and flushed skin.
- D. Tetany and complaints of stiffness of the hands.
Correct Answer: A
Rationale: Hypothyroidism causes fatigue and hair loss due to slowed metabolism. Exophthalmos/nervousness (hyperthyroidism), sweating, and tetany are unrelated.
An adolescent with IDDM is learning about a diabetic diet. He asks the nurse if he will ever be able to go out to eat with his friends again. What is the most appropriate answer for the nurse to give?
- A. You can go out with them, but you should take your own snack with you.'
- B. Yes. You will learn what foods are allowed so you can eat with your friends.'
- C. When you get food out in a restaurant, be sure to order diet soft drinks.'
- D. Eating out will not be possible on a diabetic diet. Why don't you plan to invite your friends to your house?'
Correct Answer: B
Rationale: Learning appropriate food choices allows the adolescent to eat out safely, promoting social integration and adherence to the diabetic diet.
Which diet does the nurse expect will be ordered for the client with hypothyroidism?
- A. High protein, high calorie
- B. Restricted fluids, low protein
- C. High roughage, low calorie
- D. High carbohydrate, low roughage
Correct Answer: C
Rationale: A high-roughage, low-calorie diet supports weight loss and relieves constipation in hypothyroidism.
Which nursing care measure is essential because a client has exophthalmos?
- A. Administer artificial tears.
- B. Encourage the client to wear her glasses.
- C. Promote bed rest.
- D. Monitor her pulse rate every four hours.
Correct Answer: A
Rationale: Exophthalmos (bulging eyes) in hyperthyroidism causes dry eyes, requiring artificial tears to prevent corneal damage.
The nurse evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan?
- A. Eyes sunken and skin flushed
- B. Skin moist with rapid elastic recoil
- C. Serum potassium level is 3.3 mEq/L
- D. ABG results are pH 7.25, PaCO2 30, HCO3 17
Correct Answer: B
Rationale: Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving.