Nokea
The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention?
- A. The client is alert to name but is unable to tell the nurse the location.
- B. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL.
- C. The client's vital signs are T 97.6°F, P 88, R 20, and BP 130/80.
- D. The client has a 3-cm amount of dark-red drainage on the turban dressing.
Correct Answer: B
Rationale: High output (2,500 mL vs. 1,000 mL intake) suggests diabetes insipidus, requiring immediate intervention to prevent dehydration. Disorientation, normal vitals, and drainage are less urgent.
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The diabetic client tells the nurse that breakfast is always skipped. Which response by the nurse is most appropriate?
- A. If you drink a glass of milk and eat a breakfast bar, that will be sufficient for breakfast.
- B. You should eat each meal and snack at the same time each day.
- C. If you skip breakfast, eat a high-calorie snack at midmorning.
- D. Wait to take your medication until you eat your first meal of the day.
Correct Answer: B
Rationale: Consistent meal timing is crucial for blood glucose control in diabetes.
The client is hospitalized with a tentative diagnosis of Cushing's syndrome. Which laboratory findings should the nurse expect if the diagnosis of Cushing's syndrome is confirmed? Select all that apply.
- A. Hyperglycemia
- B. Eosinophilia
- C. Hypocalcemia
- D. Hypokalemia
- E. Thrombocytopenia
- F. Elevated serum cortisol
Correct Answer: A,D,F
Rationale: Cushing's syndrome causes hyperglycemia, hypokalemia, and elevated serum cortisol due to excessive adrenocortical activity.
Which psychosocial problem should be included in the plan of care for a female client diagnosed with Cushing's syndrome?
- A. Altered glucose metabolism.
- B. Body image disturbance.
- C. Risk for suicide.
- D. Impaired wound healing.
Correct Answer: B
Rationale: Body image disturbance addresses Cushing’s physical changes (e.g., moon face, hirsutism), a key psychosocial issue. Glucose, suicide, and healing are physiological.
The nurse is admitting the client tentatively diagnosed with possible hyperaldosteronism. What should be the nurse's priority?
- A. Prepare for a computed tomography (CT) scan
- B. Give prn prescribed analgesic to treat headache
- C. Obtain an ECG to evaluate for dysrhythmias
- D. Assess for generalized weakness and fatigue
Correct Answer: C
Rationale: Obtaining an ECG is priority to detect dysrhythmias from hypokalemia caused by potassium wasting in hyperaldosteronism.
The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care?
- A. Assess the client's ability to read small print.
- B. Monitor the client's serum prothrombin time (PT) level.
- C. Teach the client how to perform a hemoglobin A1c test daily.
- D. Instruct the client to check the feet weekly.
Correct Answer: A
Rationale: Assessing the ability to read small print ensures the elderly client can read insulin labels and glucometer results, critical for safe management. PT is irrelevant, A1c is not daily, and foot checks are daily.