Nokea
The nurse is caring for the client who is experiencing symptoms associated with pheochromocytoma. Which intervention should be included in the plan of care for this client?
- A. Offer distractions such as television or music.
- B. Encourage family and friends to visit often.
- C. Assist with ambulation at least three times a day.
- D. Administer nicardipine for hypertension.
Correct Answer: D
Rationale: Nicardipine controls hypertension caused by excess catecholamines in pheochromocytoma.
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The nurse knows the diabetic client understands what 'free' foods on the exchange list means if the client excludes which one of the following from a meal plan?
- A. Iced tea
- B. Flavored water
- C. Light beer
- D. Club soda
Correct Answer: C
Rationale: Light beer contains carbohydrates and calories, unlike free foods such as iced tea, flavored water, and club soda.
Which client would the nurse identify as being at risk for developing diabetes?
- A. The client who eats mostly candy and potatoes.
- B. The 22-year-old client who has been taking birth control pills.
- C. The client who has a cousin who has had diabetes for two (2) years.
- D. The 38-year-old female who delivered a 10-pound infant.
Correct Answer: D
Rationale: Delivering a large infant (macrosomia) indicates gestational diabetes history, a strong risk factor for type 2 diabetes. Candy/potatoes, birth control, and family history are less specific.
Which statement by the client indicates a misunderstanding of the expected surgical outcome?
- A. My appearance will gradually become normal.
- B. I'll need to take replacement hormones.
- C. I'll need to see my physician regularly.
- D. The surgical incision will be inconspicuous.
Correct Answer: A
Rationale: In acromegaly, physical changes such as enlarged hands or facial features are typically irreversible, even after surgery.
In response to a question about timing of symptoms during the nursing history, when is the client most likely to describe that symptoms typically occur?
- A. After fasting more than 6 hours
- B. About 2 hours after eating a meal
- C. Late in the evening, before bedtime
- D. Early in the morning, before breakfast
Correct Answer: A
Rationale: Hyperinsulinism causes hypoglycemia, which is more likely after fasting due to excess insulin lowering blood glucose.
At 10 A.M., a client with Type 1 diabetes becomes very irritable and starts to yell at the nurse. Which initial nursing assessment should take priority?
- A. Blood pressure and pulse
- B. Color and temperature of skin
- C. Reflexes and muscle tone
- D. Serum electrolytes and glucose
Correct Answer: D
Rationale: Irritability in Type 1 diabetes suggests hypoglycemia or hyperglycemia, requiring priority assessment of serum glucose.