Nokea
The nurse is administering a pancreatic enzyme to the client diagnosed with chronic pancreatitis. Which statement best explains the rationale for administering this medication?
- A. It is an exogenous source of protease, amylase, and lipase.
- B. This enzyme increases the number of bowel movements.
- C. This medication breaks down in the stomach to help with digestion.
- D. Pancreatic enzymes help break down fat in the small intestine.
Correct Answer: A
Rationale: Pancreatic enzymes provide protease, amylase, and lipase to compensate for pancreatic insufficiency, aiding digestion. They don’t increase bowel movements or break down in the stomach.
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An elderly woman has been recently diagnosed as having Type 2 diabetes. Which of the following complaints that she has is most likely to be related to the diagnosis of diabetes mellitus?
- A. Pruritus vulvae
- B. Cough
- C. Eructation
- D. Singultus
Correct Answer: A
Rationale: Pruritus vulvae is common in diabetes due to yeast infections from elevated glucose levels.
When the nurse reviews the client's history, which assessment finding is closely associated with the client's diagnosis?
- A. Nightly leg cramps
- B. Recurrent kidney stones
- C. Loose bowel movements
- D. Excessive energy level
Correct Answer: B
Rationale: Hyperparathyroidism causes hypercalcemia, which can lead to recurrent kidney stones.
The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test?
- A. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours.
- B. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours.
- C. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test.
- D. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.
Correct Answer: C
Rationale: The fluid deprivation test involves NPO status with hourly vitals and weights to assess urine concentration, diagnosing DI. Other options describe incorrect procedures.
What is the best way to assess for hemorrhage in a client who has had a thyroidectomy?
- A. Check the pulse and blood pressure hourly.
- B. Roll the client to the side and check for evidence of bleeding.
- C. Ask the client if he/she feels blood trickling down the back of the throat.
- D. Place a hand under the client's neck and shoulders to feel bed linens.
Correct Answer: D
Rationale: Placing a hand under the neck and shoulders detects blood pooling under the incision, a common site for post-thyroidectomy hemorrhage.
The nurse observes a colleague caring for the client who had a hypophysectomy via the transsphenoidal approach 12 hours ago. Which action would require the observing nurse to intervene?
- A. Elevates the head of the client's bed to 30 degrees
- B. Gathers supplies to replace the bloody nasal packing
- C. Moisturizes the client's oral mucous membranes
- D. Places a cold washcloth over the client's swollen eyes
Correct Answer: B
Rationale: Nasal packing is left in place for 3-4 days post-hypophysectomy and should not be changed without an HCP order.