Nokea
The nurse is providing education to a client who will be having a hypophysectomy. What should the nurse be sure to include to prevent complications?
- A. Perform exercises involving bending at the hips
- B. Avoid sneezing and coughing
- C. Blow nose to clear the cold when packing is removed.
- D. Drink all liquids through a straw.
Correct Answer: B
Rationale: The nurse should instruct the client to avoid sneezing and coughing postoperatively. If the client has nasal packing, the nurse monitors drainage from the nose and postnasal drainage for the presence of cerebrospinal fluid. The nurse should remind the client to avoid drinking from a straw, sneezing, coughing, blowing the nose, and bending over to prevent dislodging the graft that seals the operative area between the cranium and nose.
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An adult client has been diagnosed with a rare disorder, Simmonds disease (panhypopituitarism), and placed on hormone replacements. What is important for the nurse to educate the client about regarding the medication?
- A. The medication must be taken as ordered until surgery is scheduled to remove the tumor.
- B. Thyroid medication will be administered for the duration of the client's life.
- C. Adhere to the medication schedule and never omit a dose.
- D. The client must take growth hormone for the duration of his life.
Correct Answer: C
Rationale: Teaching the client to adhere to the medication schedule and never to omit a dose is important. The client will have destruction of the pituitary gland so removal will be unnecessary. More than just thyroid medication will be taken. Growth hormone is only administered to children, not adult clients.
The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with?
- A. Hypothyroidism
- B. Hyperthyroidism
- C. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
- D. Diabetes insipidus (DI)
Correct Answer: B
Rationale: Clients with hyperthyroidism characteristically are restless despite feeling fatigued and weak, highly excitable, and constantly agitated. Fine tremors of the hand occur, causing unusual clumsiness. The client cannot tolerate heat and has an increased appetite but loses weight. Diarrhea also occurs. Visual changes, such as blurred or double vision, can develop. Exophthalmos, seen in clients with severe hyperthyroidism, results from enlarging muscle and fatty tissue surrounding the rear and sides of the eyeball. Hypothyroidism clinical manifestations are the opposite of what is seen in hyperthyroidism, and SIADH and DI clinical manifestations do not correlate with the symptoms manifested by the client.
The nurse is instructing a client about taking corticosteroid therapy for adrenal insufficiency. What statement made by the client indicates a need for further instruction?
- A. I will take the corticosteroid medication until my adrenal glands begin to work.'
- B. I will not omit any of the doses of my medication.'
- C. I will seek medical attention for dosage readjustments whenever I am under stress.'
- D. I will get plenty of rest and avoid exposure to infection.'
Correct Answer: A
Rationale: The nurse should explain adrenal insufficiency and the importance of lifetime corticosteroid replacement. The other statements indicate that the client is educated about medication administration.
A client with syndrome of inappropriate antidiuretic hormone (SIADH) is severely hyponatremic. What IV fluids would the nurse anticipate administering to this client?
- A. 3% hypertonic sodium chloride solution
- B. Lactated Ringer's solution
- C. 5% dextrose in water
- D. 0.9% sodium chloride solution
Correct Answer: A
Rationale: Severe hyponatremia is treated with IV administration of a 3% hypertonic sodium chloride solution. The other answers will not provide the amount of sodium required to correct the hyponatremia.
The nurse is teaching a client who is to receive lypressin nasal spray as treatment for neurogenic diabetes insipidus about administration. Which client statement indicates the need for additional teaching?
- A. I'll inhale fully after spraying the drug.'
- B. If my nose gets irritated, I'll call my physician.'
- C. I should hold the spray container upright.'
- D. While sitting up, I'll place the nozzle in my nostril.'
Correct Answer: A
Rationale: When administering lypressin nasal spray, the client should not inhale the drug. Calling the physician if he or she experiences nasal irritation, holding the container upright, and placing the nozzle in the nostril while sitting up are appropriate.