Nokea
The nurse is caring for a client with Graves' disease who has exophthalmos. The nurse should recommend that the client
- A. prevent eye dryness by applying artificial tears.
- B. use scanning techniques to move the head from side to side.
- C. take their thyroid hormone as prescribed.
- D. sleep flat on your back without any pillows.
Correct Answer: A
Rationale: Exophthalmos in Graves' disease causes protruding eyes, increasing the risk of dryness and irritation. Artificial tears help maintain moisture and protect the eyes. Sleeping flat may worsen eye protrusion, and thyroid hormone management is unrelated to exophthalmos directly.
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The nurse is assessing a client with diabetic ketoacidosis (DKA). Which of the following would be an expected finding?
- A. Thready pulse
- B. Jugular venous distention (JVD)
- C. Coarse tremors
- D. Tachycardia
- E. Orthostatic hypotension
Correct Answer: A, D, E
Rationale: DKA causes dehydration, leading to thready pulse, tachycardia, and orthostatic hypotension. JVD suggests fluid overload, and coarse tremors are not typical.
The following scenario applies to the next 1 items
The nurse in the emergency department cares for a 45-year-old female
Nurses’ Note
The client reports significant fatigue that has worsened over the past eight weeks. Additionally, the client reports constipation, hair loss, and a 3-kilogram (6.6 pounds) weight gain. She reports missing work because of difficulty concentrating and persistent fatigue.
The client is alert and fully oriented. She appears fatigued and reports dizziness when she moves quickly. Periorbital edema, various bruises, and facial swelling were noted on assessment. Peripheral pulses were intact and weak. The client denies any pain.
Vital Signs
Oral temperature 97 F (36.1o C); Pulse 51/minute; Respirations 15/minute.
BP 93/61 mm Hg; Oxygen saturation 95% on room air.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Obtain a prescription for levothyroxine, Obtain a prescription for methimazole, Have the client complete a blood transfusion consent, Obtain an order for a urine cortisol level, Initiate fall precautions.
- B. Vital Signs, Serum TSH/T3/T4 levels, Intake and Output, Cortisol Level, BUN and Creatinine.
- C. Graves' disease, Cushing's syndrome, Hypothyroidism, Systemic Lupus Erythematosus, Adrenal Insufficiency.
Correct Answer: C, A, E, B
Rationale: Fatigue, weight gain, and bradycardia suggest hypothyroidism. Levothyroxine treats it, fall precautions address dizziness, and TSH/T3/T4 and vital signs monitor progress.
The nurse is discussing the functions of the parathyroid hormone (PTH) with a student. Which of the following statements would be correct for the nurse to make? The parathyroid hormone
- A. moves calcium from bones to the bloodstream.
- B. promotes renal tubular reabsorption of calcium.
- C. controls bodily functions such as metabolism and heart rate.
- D. promotes renal tubular reabsorption of phosphorus.
- E. causes the retention of sodium and the excretion of potassium.
Correct Answer: A, B
Rationale: PTH raises blood calcium by mobilizing it from bones and increasing renal reabsorption. Metabolism and heart rate are thyroid functions, and PTH reduces, not increases, phosphorus reabsorption.
The nurse is caring for a client with Addison's disease. Which statement, if made by the client, would require follow-up?
- A. I started using table salt instead of salt substitutes.
- B. I joined a gym to train for an upcoming marathon.
- C. I recently started wearing a MedicAlert bracelet.
- D. If I start to feel ill, I should call my doctor right away.
Correct Answer: B
Rationale: Addison's causes weakness and hypotension; marathon training is excessive and risky, requiring follow-up. Salt use, MedicAlert, and calling the doctor are appropriate.
The nurse is caring for a client diagnosed with hyperparathyroidism. Which laboratory data would support this diagnosis?
- A. Potassium 4.1 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]
- B. Phosphorus 4.9 mEq/L (mmol/L) [2-4.5 mEq/L, 0.81-1.58 mmol/L]
- C. Calcium 11.2 mg/dL (2.8 mmol/L) [9-10.5 mg/dL, 2.12-2.52 mmol/L]
- D. Sodium 132 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]
Correct Answer: C
Rationale: Hyperparathyroidism increases PTH, raising blood calcium (11.2 mg/dL is elevated) and often lowering phosphorus. Potassium and sodium are not directly affected.