Nokea
The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis?
- A. Prednisone orally
- B. Fludrocortisone orally
- C. Spironolactone intramuscularly
- D. Methylprednisolone sodium succinate intravenously
Correct Answer: D
Rationale: A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addisonian crisis) that can occur as a result of the adrenalectomy. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid. Spironolactone is a potassium-sparing diuretic.
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A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Dry, scaly skin
- E. Heat intolerance
- F. Decreased body temperature
Correct Answer: B,C,D,F
Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
The nurse plans care for a client diagnosed with end-stage renal disease (ESRD). Which assessment findings does the nurse expect to find documented in the client's medical record? Select all that apply.
- A. Edema
- B. Anemia
- C. Polyuria
- D. Bradycardia
- E. Hypotension
- F. Osteoporosis
Correct Answer: A,B
Rationale: The manifestations of ESRD are the result of impaired kidney function. Two functions of the kidney are maintenance of water balance in the body and the secretion of erythropoietin, which stimulates red blood cell formation in bone marrow. Impairment of these functions results in edema and anemia. Kidney failure results in decreased urine production and increased blood pressure. Tachycardia is a result of increased fluid load on the heart. Osteoporosis is not a common finding with ESRD.
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
- A. Abnormal involuntary flexion of the extremities
- B. Abnormal involuntary extension of the extremities
- C. Upper extremity extension with lower extremity flexion
- D. Upper extremity flexion with lower extremity extension
Correct Answer: B
Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.
A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats per minute; respirations, 26 breaths per minute. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs should the nurse expect?
- A. BP 85/50 mm Hg, pulse 60 beats per minute, respirations 26 breaths per minute
- B. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute
- C. BP 130/70 mm Hg, pulse 104 beats per minute, respirations 20 breaths per minute
- D. BP 110/40 mm Hg, pulse 110 beats per minute, respirations 20 breaths per minute
Correct Answer: B
Rationale: The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. The remaining choices do not reflect the physiological changes attributed to this medication.