Nokea
Twelve hours after a transsphenoidal hypophysectomy, the client keeps clearing his throat and complains of a drip in his mouth. To accurately assess this, the nurse should test the fluid for:
- A. sugar.
- B. protein.
- C. bacteria.
- D. blood.
Correct Answer: A
Rationale: A post-nasal drip post-transsphenoidal hypophysectomy may indicate cerebrospinal fluid (CSF) leakage, which contains glucose (sugar), unlike saliva or mucus.
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An elderly client with Type 2 diabetes mellitus develops an ingrown toenail. What is the best action for the nurse to take?
- A. Put cotton under the nail and clip the nail straight across
- B. Elevate the foot immediately
- C. Apply warm, moist soaks
- D. Notify the physician
Correct Answer: D
Rationale: An ingrown toenail in a diabetic client risks infection and poor healing, requiring physician evaluation rather than self-treatment.
Which statement by the client indicates a misunderstanding of the expected surgical outcome?
- A. My appearance will gradually become normal.
- B. I'll need to take replacement hormones.
- C. I'll need to see my physician regularly.
- D. The surgical incision will be inconspicuous.
Correct Answer: A
Rationale: In acromegaly, physical changes such as enlarged hands or facial features are typically irreversible, even after surgery.
The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care?
- A. Infuse 0.9% normal saline intravenously.
- B. Administer intermediate-acting insulin.
- C. Perform blood glucometer checks daily.
- D. Monitor arterial blood gas (ABG) results.
Correct Answer: A
Rationale: IV normal saline corrects severe dehydration in HHNS, a priority collaborative intervention. Insulin is secondary, daily glucose checks are insufficient, and ABGs are less critical in HHNS.
The nurse completes teaching the client with Cushing's disease. Which statement demonstrates that the client understands measures to prevent bone resorption from corticosteroid therapy?
- A. I will increase calcium in my diet to 3000 mg daily.'
- B. I should participate in daily weight-bearing exercises.'
- C. I should limit my dietary intake of sodium and vitamin D.'
- D. I plan to rise slowly from a bed or chair to avoid falling.'
Correct Answer: B
Rationale: Daily weight-bearing exercises can help prevent bone loss and strengthen bones and muscles.
When directing the nursing assistant to weigh the client, which instruction is most important for obtaining accurate data?
- A. Have the client stand on a bedside scale.
- B. Weigh the client at the same time each day.
- C. Ask that slippers be removed when being weighed.
- D. Ask about the client's pre-disease weight.
Correct Answer: B
Rationale: Weighing the client at the same time each day ensures consistency and accounts for daily fluctuations in weight due to meals, hydration, or other factors.