Nokea
The nurse is caring for the client with elevated growth hormone (GH) levels. Which problem should the nurse exclude from the plan of care?
- A. Fluid volume deficit due to polyuria
- B. Insomnia due to soft tissue swelling
- C. Impaired communication due to speech difficulties
- D. Altered body image due to undersized hands, feet, and jaw
Correct Answer: D
Rationale: GH excess causes overgrowth of bones and soft tissues, not undersizing, so altered body image due to undersized features is excluded.
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What should be included in the nursing care plan for a client with diabetes insipidus?
- A. Blood pressure every hour
- B. Strict intake and output
- C. Urine for ketone bodies
- D. Glucose monitoring four times a day
Correct Answer: B
Rationale: Diabetes insipidus causes excessive urine output due to low antidiuretic hormone, requiring strict intake and output monitoring to assess fluid balance.
As the nurse provides care for the client newly diagnosed with a large goiter, which interventions should be implemented? Select all that apply.
- A. Observe the client's respiratory status
- B. Elevate the head of the client's bed
- C. Provide a diet high in food used.
- D. Obtain an order for a soft diet
- E. Assess for high fever
- F. Administer prescribed antibiotics
Correct Answer: A,B,D
Rationale: A large goiter can compress the trachea, necessitating respiratory monitoring, head elevation, and a soft diet to ease swallowing.
When given the news, the client denies the diagnosis and becomes angry, stating there has been a mistake in the tests. Which nursing action is most appropriate at this time?
- A. Emphasizing the importance of treatment
- B. Reassuring the client that the disease is easily managed
- C. Explaining that many people live with diabetes
- D. Listening as the client expresses current feelings
Correct Answer: D
Rationale: Listening to the client's feelings supports emotional processing and acceptance of the diagnosis.
An 18-year-old female client, 5'4 tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed?
- A. Type 1 diabetes.
- B. Type 2 diabetes.
- C. Gestational diabetes.
- D. Acanthosis nigricans.
Correct Answer: B
Rationale: Obesity (BMI ~44) and a nonhealing wound suggest type 2 diabetes, associated with insulin resistance. Type 1 is less likely, gestational diabetes requires pregnancy, and acanthosis nigricans is a symptom, not a disease.
What is the nursing priority when administering care to a client with severe hyperthyroidism?
- A. Assess for recent emotional trauma.
- B. Provide a calm, nonstimulating environment.
- C. Provide diversionary activity.
- D. Encourage range-of-motion exercises.
Correct Answer: B
Rationale: A calm, nonstimulating environment reduces hyperactivity and stress in hyperthyroidism, which exacerbates symptoms.