Nokea
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.
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The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
- A. Administer 50% dextrose (IVP).
- B. Notify the health-care provider.
- C. Move the client to the ICU.
- D. Check the serum glucose level.
Correct Answer: D
Rationale: Checking glucose confirms hypoglycemia or hyperglycemia as the cause of unconsciousness, guiding treatment. Dextrose, HCP notification, or ICU transfer follow confirmation.
The client diagnosed with hyperthyroidism is complaining of being hot and cannot sit still. Which should the nurse do based on the assessment?
- A. Continue to monitor the client.
- B. Have the UAP take the client's vital signs.
- C. Request an order for a sedative.
- D. Insist the client lie down and rest.
Correct Answer: B
Rationale: Heat intolerance and restlessness are hyperthyroidism symptoms; vital signs assess for exacerbation (e.g., thyroid storm). Monitoring, sedatives, or rest are less appropriate.
Which client statement indicates a correct understanding of corticosteroid therapy for Addison's disease?
- A. I can stop the medication if I feel better.
- B. I need to take this medication daily.
- C. I should take it only during stress.
- D. I can double the dose if I'm sick.
Correct Answer: B
Rationale: Corticosteroid therapy for Addison's disease requires daily administration to replace deficient hormones and maintain physiological balance.
The home health nurse is admitting a client diagnosed with cancer of the pancreas. Which information is the most important for the nurse to discuss with the client?
- A. Determine the client's food preferences.
- B. Ask the client if there is an advance directive.
- C. Find out about insurance/Medicare reimbursement.
- D. Explain the client should eat as much as possible.
Correct Answer: B
Rationale: An advance directive is critical for pancreatic cancer due to poor prognosis, ensuring the client’s wishes are respected. Food preferences, insurance, and eating are secondary.
Which signs/symptoms should the nurse expect to assess in the 31-year-old client who has a sustained release of growth hormone (GH)?
- A. An enlarged forehead, maxilla, and face.
- B. A six (6)-inch increase in height of the client.
- C. The client complaining of a severe headache.
- D. A systolic blood pressure of 200 to 300 mm Hg.
Correct Answer: A
Rationale: Excess GH (acromegaly) causes facial and bone enlargement (e.g., forehead, maxilla). Height increase occurs pre-puberty, headaches are nonspecific, and extreme hypertension is unrelated.