Nokea
The nurse expects to see which intervention in the plan of care for a patient who has recently been diagnosed with acromegaly?
- A. Encourage fluids
- B. Maintain leg joints in flexion
- C. Assist with activities of daily living
- D. Monitor for episodes of bleeding into the joints
Correct Answer: C
Rationale: Nursing interventions are mainly supportive. The presence of muscle weakness, joint pain, or stiffness warrants assisting with activities of daily living.
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A patient has undergone tests that indicate a deficiency of the parathyroid hormone secretion. The nurse will inform the patient of which potential complication?
- A. Osteoporosis
- B. Lethargy
- C. Laryngeal spasms
- D. Kidney stones
Correct Answer: C
Rationale: Decreased parathyroid hormone levels in the bloodstream cause a decreased calcium level. Severe hypocalcemia may result in laryngeal spasm, stridor, cyanosis, and increased possibility of asphyxia.
To which diet should a patient with Cushing syndrome adhere?
- A. Less sodium
- B. More calories
- C. Less potassium
- D. More carbohydrates
Correct Answer: A
Rationale: The diet should be lower in sodium to help decrease edema.
Which action will the nurse take for the postoperative care of the patient who had a thyroidectomy?
- A. Assessing ability to speak by asking him or her to recite name and address every hour
- B. Maintaining anatomic position of the head when moving a patient
- C. Assisting a patient to hyperextend the head to assess for muscle damage
- D. Doing voice check every 2 hours
- E. Turning, coughing every hour
- F. Checking for bleeding at the sides and the back of the head
Correct Answer: B,D,F
Rationale: The nurse should hold the head in an anatomic position when moving the patient to prevent tension on the suture line, do a voice check every 2 to 4 hours by asking the patient to say 'ah'; the patient is not turned nor is coughing recommended immediately after a thyroidectomy.
The nurse teaching a patient with type 1 diabetes mellitus (IDDM) will include which information about early signs of hypoglycemia?
- A. abdominal pain and nausea.
- B. dyspnea and pallor.
- C. flushing of the skin and headache.
- D. hunger and a trembling sensation.
Correct Answer: D
Rationale: The patient should be instructed to notify a member of the nursing staff if any signs of hypoglycemic reaction occur: excessive perspiration or trembling.
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.