Nokea
The nurse is caring for a patient with primary hyperparathyroidism who has a serum calcium level of 3.5 mmol/L and a phosphorus of 0.5 mmol/L. Which of the following nursing actions should the nurse include in the plan of care?
- A. Institute routine seizure precautions.
- B. Monitor for positive Chvostek's sign.
- C. Encourage the patient to remain on bed rest.
- D. Encourage 3000-4000 mL of oral fluids daily.
Correct Answer: D
Rationale: The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.
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The nurse is caring for a patient with possible syndrome of inappropriate antidiuretic hormone (SIADH). The patient is confused and reports a headache, muscle cramps, and twitching. Which of the following initial laboratory results should the nurse anticipate?
- A. Elevated hematocrit
- B. Decreased serum sodium
- C. Increased serum chloride
- D. Low urine specific gravity
Correct Answer: B
Rationale: When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.
Which of the following findings for a patient who takes levothyroxine to treat hypothyroidism indicates that the nurse should contact the health care provider before administering the medication?
- A. Increased thyroxine (T4) level
- B. Blood pressure 102/62 mm Hg
- C. Distant and difficult to hear heart sounds
- D. Elevated thyroid stimulating hormone level
Correct Answer: A
Rationale: An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the Synthroid.
The nurse is caring for a patient with acute adrenal insufficiency. Which of the following findings indicate that the prescribed therapies are effective?
- A. Increasing serum sodium levels
- B. Decreasing blood glucose levels
- C. Decreasing serum chloride levels
- D. Increasing serum potassium levels
Correct Answer: A
Rationale: Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.
The nurse is providing discharge teaching for a patient who had a hypophysectomy as result of a pituitary adenoma. Which of the following information should the nurse include?
- A. Oral corticosteroids as a lifelong treatment
- B. Chemotherapy to prevent recurrence of the tumour
- C. Insulin use to maintain blood glucose at normal levels
- D. Sodium restriction to prevent fluid retention and hypertension
Correct Answer: A
Rationale: Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumour, and chemotherapy will not be needed.
The nurse is caring for a patient with Cushing's syndrome who returns to the surgical unit following an adrenalectomy. Which of the following actions during the initial postoperative period has the highest priority?
- A. Monitoring for infection
- B. Protecting the patient's skin
- C. Maintaining fluid and electrolyte status
- D. Preventing severe emotional disturbances
Correct Answer: C
Rationale: After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life-threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.