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Which diet does the nurse expect will be ordered for the client with hypothyroidism?
- A. High protein, high calorie
- B. Restricted fluids, low protein
- C. High roughage, low calorie
- D. High carbohydrate, low roughage
Correct Answer: C
Rationale: A high-roughage, low-calorie diet supports weight loss and relieves constipation in hypothyroidism.
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Which nursing intervention is essential for monitoring the client's condition?
- A. Measuring intake and output
- B. Muxying blood glucose levels
- C. Inserting a Foley catheter
- D. Sending urine samples to the laboratory
Correct Answer: A
Rationale: Monitoring intake and output is critical in diabetes insipidus to assess fluid balance and the severity of polyuria.
The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis?
- A. The client has an autoimmune problem causing the destruction of the adrenal cortex.
- B. The client has been taking steroid medications for an extended period for another disease process.
- C. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol.
- D. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.
Correct Answer: B
Rationale: Iatrogenic Cushing’s results from prolonged exogenous steroid use, mimicking endogenous hypercortisolism. Autoimmune issues, pituitary tumors, and idiopathic causes are incorrect.
Which nursing interventions are most appropriate at this time? Select all that apply.
- A. Take the client's vital signs at least every hour.
- B. Press the client's vital signs at least every hour.
- C. Limit the client's activity.
- D. Administer antipyretics per order.
- E. Encourage a diet high in iodized salt.
- F. Make sure I.V. calcium gluconate is available.
Correct Answer: A,C,D,F
Rationale: In thyroid crisis, frequent vital sign monitoring, activity limitation, antipyretics, and availability of calcium gluconate address hypermetabolic state and potential hypocalcemia.
The client is diagnosed with cancer of the head of the pancreas. Which signs and symptoms should the nurse expect to assess?
- A. Clay-colored stools and dark urine.
- B. Night sweats and fever.
- C. Left lower abdominal cramps and tenesmus.
- D. Nausea and coffee-ground emesis.
Correct Answer: A
Rationale: Cancer in the head of the pancreas obstructs the bile duct, causing clay-colored stools and dark urine from jaundice. Night sweats, cramps, and coffee-ground emesis are less specific.
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?
- A. Complaints of extreme fatigue and hair loss.
- B. Exophthalmos and complaints of nervousness.
- C. Complaints of profuse sweating and flushed skin.
- D. Tetany and complaints of stiffness of the hands.
Correct Answer: A
Rationale: Hypothyroidism causes fatigue and hair loss due to slowed metabolism. Exophthalmos/nervousness (hyperthyroidism), sweating, and tetany are unrelated.