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The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first?
- A. Tell the UAP to fill the pitcher with ice cold water.
- B. Instruct the UAP to start measuring the client's I&O.
- C. Assess the client for polyuria and polydipsia.
- D. Check the client's BUN and creatinine levels.
Correct Answer: C
Rationale: Frequent water pitcher refills suggest polydipsia and polyuria, symptoms of diabetes insipidus post-head injury, requiring assessment. I&O, labs, and refilling follow.
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The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective?
- A. The client has a three (3)-pound weight gain.
- B. The client has a decreased pulse rate.
- C. The client's temperature is WNL.
- D. The client denies any diaphoresis.
Correct Answer: C
Rationale: Normal temperature indicates corrected hypothermia from hypothyroidism. Weight gain, decreased pulse, and no diaphoresis are not specific indicators.
The client is diagnosed with hypothyroidism. Which assessment data support this diagnosis?
- A. The client's vital signs are: T 99.0, P 110, R 26, and BP 145/80.
- B. The client complains of constipation and being constantly cold.
- C. The client has an intake of 780 mL and output of 256 mL.
- D. The client complains of a headache and has projectile vomiting.
Correct Answer: B
Rationale: Constipation and cold intolerance are classic hypothyroidism symptoms due to slowed metabolism. Tachycardia/hypertension, fluid imbalance, and vomiting are unrelated.
Which nursing assessment is most helpful in evaluating the status of a client with Addison's disease?
- A. Blood pressure
- B. Bowel sounds
- C. Breath sounds
- D. Heart sounds
Correct Answer: A
Rationale: Hypotension is a key sign of Addison's disease due to decreased aldosterone and cortisol.
The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test?
- A. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours.
- B. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours.
- C. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test.
- D. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.
Correct Answer: C
Rationale: The fluid deprivation test involves NPO status with hourly vitals and weights to assess urine concentration, diagnosing DI. Other options describe incorrect procedures.
The agitated client is hospitalized with tachycardia, dyspnea, and intermittent chest palpitations. The client's BP is 170/110 mm Hg, and HR is 130 bpm. The client's health history reveals thinning hair, recent 10-lb weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth, moist skin. Which prescribed intervention should be the nurse's priority?
- A. 12-lead electrocardiogram (ECG) and cardiac enzyme levels.
- B. Obtain thyroid-stimulating hormone (TSH) and free T4 levels.
- C. Propranolol 2 mg IV q15 min or until symptoms are controlled.
- D. Propylthiouracil 600-mg oral loading dose; then 200 mg orally q4h.
Correct Answer: C
Rationale: Propranolol provides rapid symptomatic relief of thyrotoxicosis by controlling cardiac and psychomotor manifestations.