Nokea
The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority?
- A. Altered body image.
- B. Activity intolerance.
- C. Impaired coping.
- D. Fluid volume deficit.
Correct Answer: D
Rationale: Adrenal infection may impair aldosterone production, causing fluid volume deficit (hypovolemia), a priority. Body image, activity, and coping are psychosocial and secondary.
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Which instruction by the nurse concerning the test procedure is most accurate?
- A. You need to eat a large meal just before the test.
- B. You can drink coffee or tea in the morning before the test.
- C. You will be given a sweetened drink before the test.
Correct Answer: C
Rationale: A glucose tolerance test involves administering a sweetened drink to assess the body's response to glucose.
Which intervention is most appropriate to add to the client's care plan to the use of the personal bleeding after a subtotal thyroidectomy?
- A. Observe for signs of hypovolemic shock.
- B. Assess for dampness at the back of the client's neck.
- C. Remove the dressing to directly inspect the wound.
- D. Weigh all gauze dressings before and after changing.
Correct Answer: B
Rationale: Assessing for dampness at the back of the neck detects bleeding that may pool behind the client.
The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client?
- A. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed.
- B. Teach the client regarding sexual functioning and androgen replacement therapy.
- C. Explain the signs and symptoms of infection and when to call the health-care provider.
- D. Demonstrate turn, cough, and deep-breathing exercises the client should perform every two (2) hours.
Correct Answer: C
Rationale: Infection signs are critical post-adrenalectomy due to immunosuppression risks. Steroid replacement is for bilateral procedures, androgen therapy is rare, and breathing exercises are inpatient-focused.
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
- A. Glucose.
- B. Potassium.
- C. Calcium.
- D. Sodium.
Correct Answer: B
Rationale: DKA causes potassium depletion due to acidosis and diuresis; replacement is anticipated to prevent arrhythmias. Glucose is not an electrolyte, and calcium/sodium are less critical.
The nurse observes a colleague caring for the client who had a hypophysectomy via the transsphenoidal approach 12 hours ago. Which action would require the observing nurse to intervene?
- A. Elevates the head of the client's bed to 30 degrees
- B. Gathers supplies to replace the bloody nasal packing
- C. Moisturizes the client's oral mucous membranes
- D. Places a cold washcloth over the client's swollen eyes
Correct Answer: B
Rationale: Nasal packing is left in place for 3-4 days post-hypophysectomy and should not be changed without an HCP order.