Nokea
The nurse determined that the client's fluid volume deficit from HHNS has resolved. Which serum laboratory finding led to the nurse's conclusion?
- A. Decreased glucose
- B. Decreased sodium
- C. Decreased osmolality
- D. Decreased potassium
Correct Answer: C
Rationale: A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving.
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The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis?
- A. The client has an autoimmune problem causing the destruction of the adrenal cortex.
- B. The client has been taking steroid medications for an extended period for another disease process.
- C. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol.
- D. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.
Correct Answer: B
Rationale: Iatrogenic Cushing’s results from prolonged exogenous steroid use, mimicking endogenous hypercortisolism. Autoimmune issues, pituitary tumors, and idiopathic causes are incorrect.
The nurse is admitting a client to rule out aldosteronism. Which assessment data support the client's diagnosis?
- A. Temperature.
- B. Pulse.
- C. Respirations.
- D. Blood pressure.
Correct Answer: D
Rationale: Elevated blood pressure is a hallmark of aldosteronism due to sodium retention and fluid overload. Temperature, pulse, and respirations are less specific.
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?
- A. Recommend lying in the prone position with legs extended.
- B. Maintain a tripod position over the bedside table.
- C. Place in side-lying position with knees flexed.
- D. Encourage a supine position with a pillow under the knees.
Correct Answer: C
Rationale: Side-lying with knees flexed reduces abdominal tension, easing pancreatitis pain. Prone, tripod, and supine positions are less effective.
When the nurse conducts an admission history, which subjective symptom is the client likely to describe?
- A. Difficulty urinating
- B. Intolerance to cold
- C. Profuse perspiration
- D. Excessive appetite
Correct Answer: B
Rationale: Intolerance to cold is a common symptom of myxedema due to decreased metabolic rate.
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.