Nokea
The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following?
- A. Congestive heart failure
- B. Hypovolemic shock
- C. Infection
- D. Volume overload
Correct Answer: B
Rationale: The correct answer is B: Hypovolemic shock. After pituitary surgery, patients are at risk for hypovolemic shock due to potential intraoperative blood loss and fluid shifts. Monitoring for signs of shock, such as hypotension and tachycardia, is crucial for early intervention. A: Congestive heart failure is less likely immediately post-surgery. C: Infection is a concern but not the highest priority in the immediate postoperative period. D: Volume overload is not a common immediate complication of pituitary surgery.
You may also like to solve these questions
An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis?
- A. Elevated adrenocorticotropic hormone
- B. Elevated cortisol levels
- C. Elevated T and T 3 4
- D. Elevated thyroid-stimulating hormone
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Elevated T and T3/T4 levels are indicative of primary hypothyroidism, such as myxedema. In this case, the patient presents with classic symptoms of hypothyroidism, including altered mental status, hypothermia, and heart failure. Elevated T3/T4 levels confirm the diagnosis.
Summary of Incorrect Choices:
A: Elevated adrenocorticotropic hormone is associated with adrenal disorders, not hypothyroidism.
B: Elevated cortisol levels suggest Cushing's syndrome, a condition of excess cortisol production, not hypothyroidism.
D: Elevated thyroid-stimulating hormone is seen in primary hypothyroidism, but in myxedema, the issue is not with TSH but with T3/T4 levels.
The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient’s condition is
- A. prerenal.
- B. postrenal.
- C. intrarenal.
- D. not renal related.
Correct Answer: C
Rationale: The correct answer is C: intrarenal. The presence of sediment, crystals, and bacteria in the urinalysis indicates an issue within the kidneys themselves. The flank pain suggests renal involvement. Prerenal would involve issues before the kidneys, such as inadequate blood flow. Postrenal would involve issues after the kidneys, such as urinary tract obstruction. Not renal related is incorrect as the symptoms and urinalysis findings clearly point to a renal issue.
The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient’s urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing
- A. diabetes insipidus.
- B. diabetic ketoacidosis.
- C. hyperosmolar hyperglycemic syndrome.
- D. syndrome of inappropriate secretion of antidiuretic hormone.
Correct Answer: A
Rationale: Rationale: A patient with head trauma may develop diabetes insipidus due to damage to the hypothalamus or pituitary gland, leading to decreased secretion of antidiuretic hormone (ADH). This results in excessive urine output and thirst. Other options are incorrect because:
B: Diabetic ketoacidosis is associated with high blood sugar and ketones, not increased urine output.
C: Hyperosmolar hyperglycemic syndrome is characterized by extreme hyperglycemia, not increased urine output.
D: Syndrome of inappropriate secretion of antidiuretic hormone results in decreased urine output due to excess ADH.
The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best?
- A. Assess the patient’s hearing.
- B. Assess the patient’s lungs.
- C. Decrease IV fluids once the diuretic has been administered.
- D. Give extra doses before giving radiological contrast agents.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's lungs. In rhabdomyolysis, muscle breakdown releases myoglobin which can cause kidney damage. Mannitol is given to prevent kidney damage by promoting diuresis. However, mannitol can also cause fluid overload and pulmonary edema. Therefore, assessing the patient's lungs is crucial to monitor for signs of fluid overload and prevent complications.
A: Assessing the patient's hearing is not directly related to the management of rhabdomyolysis and mannitol administration.
C: Decreasing IV fluids after administering a diuretic like mannitol can lead to inadequate fluid resuscitation and worsening kidney injury.
D: Giving extra doses before radiological contrast agents is not necessary in the context of rhabdomyolysis and mannitol administration.
A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of:
- A. adrenal insufficiency.
- B. diabetic ketoacidosis.
- C. hyperosmolar, hyperglycemic state.
- D. hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: diabetic ketoacidosis. When an insulin pump fails, the patient may experience a sudden decrease in insulin delivery, leading to a potential rise in blood glucose levels. This can trigger diabetic ketoacidosis, characterized by hyperglycemia, ketosis, and acidosis. Monitoring for signs such as increased thirst, frequent urination, fruity breath odor, and rapid breathing is crucial.
Incorrect choices:
A: Adrenal insufficiency is not directly related to insulin pump failure.
C: Hyperosmolar, hyperglycemic state is more common in type 2 diabetes and typically occurs with extreme hyperglycemia, not sudden pump failure.
D: Hypoglycemia is less likely with pump failure due to decreased insulin delivery.