Nokea
The nurse is providing postoperative care for a patient who had a bilateral adrenalectomy. Which assessment information requires the most rapid action by the nurse?
- A. The blood glucose is 8 mmol/L.
- B. The lungs have bibasilar crackles.
- C. The patient's BP is 88/50 mm Hg.
- D. The patient has 5/10 incisional pain.
Correct Answer: C
Rationale: The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.
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The nurse is caring for a patient with a diagnosis of Cushing's syndrome. Which of the following data should the nurse anticipate finding during the admission assessment?
- A. Persistently low blood pressure
- B. Bronzed appearance of the skin
- C. Decreased axillary and pubic hair
- D. Purplish red streaks on the abdomen
Correct Answer: D
Rationale: Purplish-red striae on the abdomen are a common clinical manifestation of Cushing's syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.
The nurse is caring for a patient with possible syndrome of inappropriate antidiuretic hormone (SIADH). The patient is confused and reports a headache, muscle cramps, and twitching. Which of the following initial laboratory results should the nurse anticipate?
- A. Elevated hematocrit
- B. Decreased serum sodium
- C. Increased serum chloride
- D. Low urine specific gravity
Correct Answer: B
Rationale: When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.
A patient is suspected of having a pituitary tumour causing panhypopituitarism. During assessment of the patient, which of the following findings should the nurse anticipate?
- A. High blood pressure
- B. Elevated blood glucose
- C. Tachycardia and cardiac palpitations
- D. Changes in secondary sex characteristics
Correct Answer: D
Rationale: Changes in secondary sex characteristics are associated with decreases in follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in adrenocorticotropic hormone (ACTH) and cortisol. Bradycardia is likely due to the decrease in thyroid-stimulating hormone (TSH) and thyroid hormones associated with panhypopituitarism.
Which of the following actions should the nurse take first when caring for a patient who has just arrived on the unit after a thyroidectomy?
- A. Check the dressing for bleeding.
- B. Assess respiratory rate and effort.
- C. Take the blood pressure and pulse.
- D. Support the patient's head with pillows.
Correct Answer: B
Rationale: Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany, and the priority nursing action is to assess the airway. The other actions are also part of the standard nursing care post-thyroidectomy but are not as high in priority.
A few hours after returning to the surgical nursing unit, a patient who has undergone a subtotal thyroidectomy develops laryngeal stridor and a cramp in the right hand. Which of the following actions should the nurse anticipate implementing first?
- A. Infuse IV calcium gluconate.
- B. Suction the patient's airway.
- C. Prepare for endotracheal intubation.
- D. Assist with emergency tracheotomy
Correct Answer: A
Rationale: The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheotomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.