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 client diagnosed with cancer of the pancreas is being discharged to start chemotherapy in the HCP's office. Which statement made by the client indicates the client understands the discharge instructions?
- A. I will have to see the HCP every day for six (6) weeks for my treatments.
- B. I should write down all my questions so I can ask them when I see the HCP.
- C. I am sure this is not going to be a serious problem for me to deal with.
- D. The nurse will give me an injection in my leg and I will get to go home.
Correct Answer: B
Rationale: Writing down questions ensures effective communication with the HCP, indicating understanding. Daily visits, downplaying severity, and leg injections are incorrect.
A client is diagnosed as having insulin-dependent diabetes mellitus (IDDM). She received regular insulin at 7:30 A.M. When is she most apt to develop a hypoglycemic reaction?
- A. Mid-morning
- B. Mid-afternoon
- C. Early evening
- D. During the night
Correct Answer: A
Rationale: Regular insulin peaks 2-4 hours after administration, making mid-morning (9:30-11:30 A.M.) the most likely time for hypoglycemia.
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.
The nurse is teaching the client diagnosed with type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?
- A. A submarine sandwich, potato chips, and diet cola.
- B. Four (4) slices of a supreme thin-crust pizza and milk.
- C. Smoked turkey sandwich, celery sticks, and unsweetened tea.
- D. A roast beef sandwich, fried onion rings, and a cola.
Correct Answer: C
Rationale: A turkey sandwich, celery, and unsweetened tea are low-carb, low-fat, and diabetes-friendly. Other options are high in carbs or fats, worsening glycemic control.
The nurse is teaching the client who lacks parathyroid hormone (PTH) about foods to consume. Which items should be included on a list of appropriate foods for the client?
- A. Dark green vegetables, soybeans, and tofu
- B. Spinach, strawberries, and yogurt
- C. Whole grain bread, milk, and liver
- D. Rhubarb, yellow vegetables, and fish
Correct Answer: A
Rationale: High-calcium foods like dark green vegetables, soybeans, and tofu are appropriate for hypoparathyroidism to address chronic hypocalcemia.