Nokea
When the nurse conducts an admission history, which subjective symptom is the client likely to describe?
- A. Difficulty urinating
- B. Intolerance to cold
- C. Profuse perspiration
- D. Excessive appetite
Correct Answer: B
Rationale: Intolerance to cold is a common symptom of myxedema due to decreased metabolic rate.
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In which position should the client be maintained after the subtotal thyroidectomy?
- A. Supine
- B. Sims'
- C. Semi-Fowler's
- D. Recumbent
Correct Answer: C
Rationale: Semi-Fowler's position reduces swelling and promotes airway patency after thyroidectomy.
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of 'altered nutrition: less than body requirements.' Which collaborative intervention should the nurse include in the plan of care?
- A. Continuous feedings via (PEG) tube.
- B. Have the family bring in foods from home.
- C. Assess for food preferences.
- D. Refer to the dietitian.
Correct Answer: D
Rationale: Referring to a dietitian ensures specialized nutritional planning for pancreatic cancer, addressing malabsorption and weight loss. PEG feedings, family foods, and preferences are secondary.
Which statement indicates that the client has misunderstood the nurse's teaching?
- A. I may need more insulin during times of stress.
- B. I may need more food when exercising strenuously.
- C. My insulin needs may change as I get older.
- D. My dependence on insulin may stop eventually.
Correct Answer: D
Rationale: Type 1 diabetes requires lifelong insulin therapy, so dependence will not stop.
Which question should the nurse ask when assessing the client for an endocrine dysfunction?
- A. Have you noticed any pain in your legs when walking?
- B. Have you had any unexplained weight loss?
- C. Have you noticed any change in your bowel movements?
- D. Have you experienced any joint pain or discomfort?
Correct Answer: B
Rationale: Unexplained weight loss is a hallmark symptom of endocrine disorders like hyperthyroidism or diabetes mellitus, making it a key assessment question. Leg pain relates to vascular issues, bowel changes are less specific, and joint pain is more musculoskeletal.
Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information?
- A. Antibiotics will help to prevent respiratory complications following surgery.
- B. Meningitis is a complication following transsphenoidal hypophysectomy.
- C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
- D. Hormone replacement is essential after hypophysectomy.
Correct Answer: B
Rationale: The transsphenoidal approach through the mouth increases the risk of meningitis due to oral bacteria, necessitating prophylactic antibiotics.