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The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply.
- A. Epistaxis
- B. Pallor
- C. Rapid respiratory rate
- D. Bounding pulse
- E. Hypotension
Correct Answer: B,C,E
Rationale: The patient at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.
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The nurses assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention?
- A. Oral calcium chloride and vitamin D
- B. IV calcium gluconate
- C. STAT levothyroxine
- D. Administration of parathyroid hormone (PTH)
Correct Answer: B
Rationale: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.
A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend?
- A. Activity limitation to conserve energy
- B. Consumption of a high-protein diet
- C. Use of OTC vitamin D and calcium supplements
- D. Passive range-of-motion exercises
Correct Answer: B
Rationale: Muscle wasting can be partly addressed through increased protein intake. Passive ROM exercises maintain flexibility, but do not build muscle mass. Vitamin D and calcium supplements do not decrease muscle wasting. Activity limitation would exacerbate the problem.
A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient?
- A. Side-lying (lateral) with one pillow under the head
- B. Head of the bed elevated 30 degrees and no pillows placed under the head
- C. Semi-Fowlers with the head supported on two pillows
- D. Supine, with a small roll supporting the neck
Correct Answer: C
Rationale: When moving and turning the patient, the nurse carefully supports the patients head and avoids tension on the sutures. The most comfortable position is the semi-Fowlers position, with the head elevated and supported by pillows.
While assisting with the surgical removal of an adrenal tumor, the OR nurse is aware that the patients vital signs may change upon manipulation of the tumor. What vital sign changes would the nurse expect to see?
- A. Hyperthermia and tachypnea
- B. Hypertension and heart rate changes
- C. Hypotension and hypothermia
- D. Hyperthermia and bradycardia
Correct Answer: B
Rationale: Manipulation of the tumor during surgical excision may cause release of stored epinephrine and norepinephrine, with marked increases in BP and changes in heart rate. The use of sodium nitroprusside and alpha-adrenergic blocking agents may be required during and after surgery. While other vital sign changes may occur related to surgical complications, the most common changes are related to hypertension and changes in the heart rate.
The nurse is assessing a patient diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find?
- A. Hair loss
- B. Moon face
- C. Bulging eyes
- D. Fatigue
Correct Answer: C
Rationale: Clinical manifestations of the endocrine disorder Graves disease include exophthalmos (bulging eyes) and fine tremor in the hands. Graves disease is not associated with hair loss, a moon face, or fatigue.