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The nurse is caring for a patient with Graves' disease who has to,2026. 11:3.29. following actionspl. All is included in the plan of care?
- A. Apply eye patches to protect the cornea from irritation.
- B. Place cold packs on the eyes to
- C. Elevate the head of the patient's bed to reduce periorbital
- D. Teach the patient to blink every few seconds to lubric
Correct Answer: C
Rationale: The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.
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The nurse is providing postoperative care for a patient who had a bilateral adrenalectomy. Which assessment information requires the most rapid action by the nurse?
- A. The blood glucose is 8 mmol/L.
- B. The lungs have bibasilar crackles.
- C. The patient's BP is 88/50 mm Hg.
- D. The patient has 5/10 incisional pain.
Correct Answer: C
Rationale: The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.
The nurse is caring for a patient with hypertension who is diagnosed with a pheochromocytoma. Which of the following findings should the nurse monitor in the patient?
- A. Flushing
- B. Headache
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: B
Rationale: The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe pounding headache, diaphoresis, and abdominal or chest pain. Elevated blood glucose may also occur because of sympathetic nervous system stimulation. Bradycardia and flushing would not be expected.
The nurse is assessing a patient with suspected acromegaly at the clinic. When completing the subjective inquiry, which question should the nurse ask?
- A. Have you had a recent head injury?
- B. Do you have to wear larger shoes now?
- C. Are you experiencing tremors or anxiety?
- D. Is there any family history of acromegaly?
Correct Answer: B
Rationale: Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.
A patient is being treated with a medication to block the effect of antidiuretic hormone to control the symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings indicates that the medication is effective?
- A. Decreased peripheral edema
- B. Increased weight
- C. Increased urine specific gravity
- D. Increased urinary output
Correct Answer: D
Rationale: Agents that block the effect of ADH on the renal tubules may be prescribed, thereby allowing more dilution of urine leading to an increased urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.
The nurse is assessing a patient who has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy and obtains these data. Which of the following information is most important to communicate to the surgeon?
- A. The patient is sleepy and hard to arouse.
- B. The patient has increasing swelling of the neck.
- C. The patient is complaining of 7/10 incisional pain.
- D. The patient's cardiac monitor shows a heart rate of 112.
Correct Answer: B
Rationale: The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.