Nokea
The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?
- A. Temperature and oxygen saturation
- B. Heart rate and BP
- C. Breath sounds and bowel sounds
- D. Color, warmth, movement, and sensation of extremities
Correct Answer: B
Rationale: The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The patients condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, BP and heart rate monitoring are priorities over the other listed assessments.
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You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan?
- A. Risk for injury related to weakness
- B. Ineffective breathing pattern related to muscle weakness
- C. Risk for loneliness related to disturbed body image
- D. Autonomous dysreflexia related to neurologic changes
Correct Answer: A
Rationale: The nursing priority is to decrease the risk of injury by establishing a protective environment. The patient who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners or furniture. The patients breathing will not be affected and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the patient, but safety is a priority.
A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy?
- A. The patients diet should be low protein with ample fat
- B. The patient may experience short-term changes in cognition
- C. The patient is at an increased risk for developing infection
- D. The patient is at a decreased risk for development of thrombophlebitis and thromboembolism
Correct Answer: C
Rationale: The patient is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. Diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects.
A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding?
- A. The patients pituitary function is compromised
- B. The patients adrenal insufficiency is not treatable
- C. The patient has insufficient hypothalamic function
- D. The patient would benefit from surgery
Correct Answer: A
Rationale: An adrenal response to the administration of a stimulating hormone suggests inadequate production of the stimulating hormone. In this case, ACTH is produced by the pituitary and, consequently, pituitary hypofunction is suggested. Hypothalamic function is not relevant to the physiology of this problem. Treatment exists, although surgery is not likely indicated.
A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patients nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply.
- A. Foods high in vitamin D
- B. Foods high in calories
- C. Foods high in protein
- D. Foods high in calcium
- E. Foods high in sodium
Correct Answer: A,C,D
Rationale: Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the patient in selecting appropriate foods that are also low in sodium and calories.
The nurses assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention?
- A. Oral calcium chloride and vitamin D
- B. IV calcium gluconate
- C. STAT levothyroxine
- D. Administration of parathyroid hormone (PTH)
Correct Answer: B
Rationale: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.