Nokea
The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider?
- A. Serum sodium of 112 mEq/L and a headache.
- B. Serum potassium of 5.0 mEq/L and a heightened awareness.
- C. Serum calcium of 10 mg/dL and tented tissue turgor.
- D. Serum magnesium of 1.2 mg/dL and large urinary output.
Correct Answer: A
Rationale: Severe hyponatremia (112 mEq/L) and headache in SIADH risk seizures, requiring immediate HCP notification. Other findings are less critical or unrelated.
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Which assessment technique is most appropriate when checking for laryngeal nerve damage in a client who has had a thyroidectomy?
- A. Turning the client's head from side to side
- B. Occurifying the client's swallowing
- C. Looking for tracheal deviation
- D. Asking the client to say 'Ah'
Correct Answer: D
Rationale: Asking the client to say 'Ah' assesses vocal cord function, which can be affected by laryngeal nerve damage.
Which signs/symptoms indicate the client with hypothyroidism is not taking enough thyroid hormone?
- A. Complaints of weight loss and fine tremors.
- B. Complaints of excessive thirst and urination.
- C. Complaints of constipation and being cold.
- D. Complaints of delayed wound healing and belching.
Correct Answer: C
Rationale: Constipation and cold intolerance indicate persistent hypothyroidism due to inadequate thyroid hormone. Weight loss/tremors, thirst, and healing/belching are unrelated.
The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client?
- A. Refer the client to the American Diabetes Association.
- B. Do not take any over-the-counter (OTC) medications.
- C. Take the prescribed insulin even when unable to eat because of illness.
- D. Explain the need to get the annual flu and pneumonia vaccines.
Correct Answer: C
Rationale: Continuing insulin during illness prevents DKA by maintaining glucose control. ADA referral, avoiding OTC meds, and vaccines are secondary.
Which techniques are correct when using an electronic and the patient's capillary blood glucose level? Select all that apply.
- A. Clean the client's finger with povidone-iodine (Betadine).
- B. Take a set of vital signs before the test.
- C. Pierce the central pad of the client's finger.
- D. Apply a large drop of blood to a test strip or area.
- E. Don gloves before piercing the client's finger.
- F. Perform a quality control before the test.
Correct Answer: C,E,F
Rationale: Correct techniques include piercing the finger pad, wearing gloves, and performing quality control for accurate glucometer readings.
Preoperatively, which information is most important to teach the client before the subtotal thyroidectomy?
- A. Techniques for changing positions
- B. Reasons for performing leg exercises
- C. The necessity for daily dressing changes
- D. Postoperative use of the incentive spirometer
Correct Answer: D
Rationale: Using an incentive spirometer postoperatively helps prevent respiratory complications after thyroidectomy.