Nokea
The nurse is assessing a client in an outpatient clinic. Which assessment data are a risk factor for developing pheochromocytoma?
- A. A history of skin cancer.
- B. A history of high blood pressure.
- C. A family history of adrenal tumors.
- D. A family history of migraine headaches.
Correct Answer: C
Rationale: A family history of adrenal tumors increases pheochromocytoma risk, as it’s a catecholamine-secreting adrenal tumor. Skin cancer, hypertension, and migraines are unrelated.
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The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority?
- A. Altered body image.
- B. Activity intolerance.
- C. Impaired coping.
- D. Fluid volume deficit.
Correct Answer: D
Rationale: Adrenal infection may impair aldosterone production, causing fluid volume deficit (hypovolemia), a priority. Body image, activity, and coping are psychosocial and secondary.
Which finding indicates a potential complication of thyroid crisis that the nurse should prioritize?
- A. Heart rate of 140 beats per minute
- B. Blood pressure of 120/80 mmHg
- C. Temperature of 98.6°F
- D. Respiratory rate of 16 breaths per minute
Correct Answer: A
Rationale: A heart rate of 140 beats per minute indicates severe tachycardia, a life-threatening complication of thyroid crisis requiring immediate intervention.
The nurse is administering morning medications. Which medications should the nurse administer question?
- A. The oral carafate to a client who has not eaten breakfast.
- B. The subcutaneous insulin to a client refusing blood glucose checks.
- C. The levothyroxine PO to a client diagnosed with hypothyroidism.
- D. The sliding scale insulin to a client whose blood glucose level is 320 mg/dL.
Correct Answer: B
Rationale: Insulin without glucose checks risks hypoglycemia, requiring clarification. Carafate timing, levothyroxine, and sliding-scale insulin are appropriate.
Immediately after surgery, the nurse assesses the client for bleeding. Where is the best location to assess for bleeding?
- A. The skull
- B. The nose
- C. The ear canal
- D. The tongue
Correct Answer: B
Rationale: Trans-sphenoidal hypophysectomy is performed through the nasal cavity, so bleeding is most likely to be observed in the nose.
The agitated client is hospitalized with tachycardia, dyspnea, and intermittent chest palpitations. The client's BP is 170/110 mm Hg, and HR is 130 bpm. The client's health history reveals thinning hair, recent 10-lb weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth, moist skin. Which prescribed intervention should be the nurse's priority?
- A. 12-lead electrocardiogram (ECG) and cardiac enzyme levels.
- B. Obtain thyroid-stimulating hormone (TSH) and free T4 levels.
- C. Propranolol 2 mg IV q15 min or until symptoms are controlled.
- D. Propylthiouracil 600-mg oral loading dose; then 200 mg orally q4h.
Correct Answer: C
Rationale: Propranolol provides rapid symptomatic relief of thyrotoxicosis by controlling cardiac and psychomotor manifestations.