Nokea
The nurse is caring for a client with hypoparathyroidism. When the nurse taps the client's facial nerve, the client's mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels?
- A. Positive Chvostek sign
- B. Positive Trousseau sign
- C. Positive paresthesia
- D. Positive Babinski sign
Correct Answer: A
Rationale: If a nurse taps the client's facial nerve (which lies under the tissue in front of the ear), the client's mouth twitches and the jaw tightens. The response is identified as a positive Chvostek sign. A positive Trousseau sign is elicited by placing a BP cuff on the upper arm, inflating it between the systolic and diastolic BP, and waiting 3 minutes. The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Positive Babinski sign is elicited by stroking the sole of the foot. Paresthesia is not a symptom that can be elicited; it is felt by the client.
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The nurse is reviewing a client's history which reveals that the client has had an oversecretion of growth hormone (GH) that occurred before puberty. The nurse interprets this as resulting in which condition?
- A. Gigantism
- B. Dwarfism
- C. Acromegaly
- D. Simmonds disease
Correct Answer: A
Rationale: When oversecretion of GH occurs before puberty, gigantism results. Dwarfism occurs when secretion of GH is insufficient during childhood. Oversecretion of GH during adulthood results in acromegaly. An absence of pituitary hormonal activity causes Simmonds disease.
The nurse is providing education to a client who will be having a hypophysectomy. What should the nurse be sure to include to prevent complications?
- A. Perform exercises involving bending at the hips
- B. Avoid sneezing and coughing
- C. Blow nose to clear the cold when packing is removed.
- D. Drink all liquids through a straw.
Correct Answer: B
Rationale: The nurse should instruct the client to avoid sneezing and coughing postoperatively. If the client has nasal packing, the nurse monitors drainage from the nose and postnasal drainage for the presence of cerebrospinal fluid. The nurse should remind the client to avoid drinking from a straw, sneezing, coughing, blowing the nose, and bending over to prevent dislodging the graft that seals the operative area between the cranium and nose.
A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client?
- A. Glaucoma
- B. Corneal abrasions
- C. Retinal detachment
- D. Pressure on the optic nerve
Correct Answer: D
Rationale: Partial blindness may result from pressure on the optic nerve. Glaucoma does not occur suddenly, and the client did not report injury to suspect corneal abrasions or retinal detachment.
A client is scheduled for a hypophysectomy for the management of a pituitary tumor. What is the nurse priority when caring for this client? Select all that apply.
- A. Assure the client that he will make it through the surgery without any difficulty.
- B. Help the client cope with changes in physical appearance.
- C. Pace activities to accommodate the client's fatigue.
- D. Relieve discomfort from headaches, abdominal distention, and skeletal pain.
- E. Encourage self-care and activities as client's endurance permits.
Correct Answer: B,C,D,E
Rationale: Until the client has surgery or receives radiation treatment, nursing priorities include helping the client cope with changes in physical appearance; pacing activities to accommodate the client's fatigue; and relieving discomfort from headaches, abdominal distention resulting from organ enlargement, and skeletal pain. Assuring the client that he will make it through the surgery without any difficulty is not appropriate as it dismisses the client's concerns and does not address specific care priorities.
A client with syndrome of inappropriate antidiuretic hormone (SIADH) is severely hyponatremic. What IV fluids would the nurse anticipate administering to this client?
- A. 3% hypertonic sodium chloride solution
- B. Lactated Ringer's solution
- C. 5% dextrose in water
- D. 0.9% sodium chloride solution
Correct Answer: A
Rationale: Severe hyponatremia is treated with IV administration of a 3% hypertonic sodium chloride solution. The other answers will not provide the amount of sodium required to correct the hyponatremia.