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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The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply.
- A. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days.
- B. Discuss ways to cope with the emotional lability.
- C. Notify the HCP if taking over-the-counter medication.
- D. Carry a medical identification card or bracelet.
- E. Teach how to take thyroid medications correctly.
Correct Answer: B,C,D
Rationale: Coping with emotional lability, reporting OTC meds, and carrying ID address hyperthyroidism’s effects and safety. Rapid weight loss is expected, and thyroid meds are for hypothyroidism.
The nurse is caring for the client with SIADH. Which interventions should the nurse plan to implement? Select all that apply.
- A. Obtain the weight near the same time each morning.
- B. Place the client on a fluid-restricted diet as prescribed.
- C. Prepare to give a 500-mL NaCl intravenous fluid bolus.
- D. Administer furosemide intravenously as prescribed.
- E. Monitor for hyperactive reflexes and heightened alertness.
Correct Answer: A,B,D
Rationale: Daily weights monitor fluid retention, fluid restriction treats hyponatremia, and furosemide addresses fluid overload in SIADH.
Which characteristic symptom of the client's disorder would the nurse expect to find during an assessment?
- A. Polyphagia
- B. Polyuria
- C. Glycosuria
- D. Hyperglycemia
Correct Answer: B
Rationale: Diabetes insipidus is characterized by a deficiency of antidiuretic hormone, leading to excessive urination (polyuria) due to the kidneys' inability to conserve water.
A clinic nurse is teaching the client newly diagnosed with hypothyroidism. Which instructions should the nurse provide about taking levothyroxine sodium? Select all that apply.
- A. Take the medication 1 hour before or 2 hours after breakfast.
- B. Call the clinic if the pulse before taking the medication is greater than 100 beats per minute.
- C. Report adverse drug effects, including weight gain, cold intolerance, and alopecia.
- D. Take this drug as prescribed; it replaces thyroid hormone thatå‚¾å‘ diminished or absent.
- E. Have frequent laboratory monitoring to be sure your levels of T3 and T4 decrease.
Correct Answer: A,B,D
Rationale: Taking levothyroxine on an empty stomach ensures absorption, notifying the clinic for tachycardia prevents overdose, and taking it as prescribed replaces deficient hormone.
Which sign is most suggestive that a client with type 2 diabetes is developing hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. The client's serum glucose level is 650 mg/dL.
- B. The client's urinary output is 3,000 mL/24 hours.
- C. The client's skin is cool and moist.
- D. The client's urine contains acetone.
Correct Answer: A
Rationale: A serum glucose level of 650 mg/dL is characteristic of HHNS, indicating severe hyperglycemia.