Nokea
The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care?
- A. Diarrhea due to gastrointestinal (GI) hypermotility
- B. Imbalanced nutrition due to insufficient calorie intake
- C. Activity intolerance due to increased metabolic rate
- D. Anxiety due to forgetfulness and slowed speech
Correct Answer: D
Rationale: Forgetfulness and slowed speech that occur with hypothyroidism can cause the client to be anxious.
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Which characteristic findings would the nurse expect to assess in a client with Addison's disease? Select all that apply.
- A. Salt craving
- B. Skin blemishes
- C. Moon-shaped face
- D. Bronzed skin
- E. Hypoglycemia
- F. Weight loss
Correct Answer: A,D,E,F
Rationale: Addison's disease causes adrenal insufficiency, leading to salt craving, bronzed skin, hypoglycemia, and weight loss.
Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison’s disease?
- A. Discuss the importance of tapering medications when discontinuing medication.
- B. Explain the dose may need to be increased during times of stress or infection.
- C. Instruct the client to take medication on an empty stomach with a glass of water.
- D. Encourage the client to wear clean white socks when wearing tennis shoes.
Correct Answer: B
Rationale: Addison’s disease requires glucocorticoid replacement, and doses must be increased during stress or infection to mimic the body’s natural cortisol response and prevent adrenal crisis. Tapering applies to exogenous steroid cessation, empty stomach intake is incorrect, and socks are irrelevant.
Twelve hours after a transsphenoidal hypophysectomy, the client keeps clearing his throat and complains of a drip in his mouth. To accurately assess this, the nurse should test the fluid for:
- A. sugar.
- B. protein.
- C. bacteria.
- D. blood.
Correct Answer: A
Rationale: A post-nasal drip post-transsphenoidal hypophysectomy may indicate cerebrospinal fluid (CSF) leakage, which contains glucose (sugar), unlike saliva or mucus.
Which laboratory data make the nurse suspect the client with primary hyperparathyroidism is experiencing a complication?
- A. A serum creatinine level of 2.8 mg/dL.
- B. A calcium level of 9.2 mg/dL.
- C. A serum triglyceride level of 130 mg/dL.
- D. A sodium level of 135 mEq/L.
Correct Answer: A
Rationale: Elevated creatinine (2.8 mg/dL) suggests kidney damage, a complication of hyperparathyroidism’s hypercalcemia. Normal calcium, triglycerides, and sodium are unremarkable.
Which statement indicates that a client with an elevated 2-hour postprandial blood glucose level understands the significance of the screening test?
- A. I need to eat less frequently.
- B. I need to consult my physician.
- C. I need to begin taking insulin.
Correct Answer: B
Rationale: An elevated postprandial glucose level warrants further medical evaluation by a physician.