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Which documentation finding provides the best indication that the client has successfully avoided an adrenal (addisonian) crisis after surgery?
- A. The client's pedal edema has lessened.
- B. Capillary blood glucose level is within normal limits.
- C. Vital signs are within preoperative ranges.
Correct Answer: C
Rationale: Stable vital signs indicate the absence of adrenal crisis, characterized by hypotension and shock.
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The client diagnosed with diabetes complains of a curtain being drawn across the eyes. Which should the nurse implement first?
- A. Assess the eyes using an ophthalmoscope.
- B. Tell the client to keep the eyes closed.
- C. Notify the health-care provider (HCP).
- D. Call the Rapid Response Team (RRT).
Correct Answer: C
Rationale: A curtain-like vision loss suggests retinal detachment, a diabetic complication requiring urgent HCP notification. Ophthalmoscopy, closing eyes, or RRT are inappropriate first steps.
As the nurse provides care for the client newly diagnosed with a large goiter, which interventions should be implemented? Select all that apply.
- A. Observe the client's respiratory status
- B. Elevate the head of the client's bed
- C. Provide a diet high in food used.
- D. Obtain an order for a soft diet
- E. Assess for high fever
- F. Administer prescribed antibiotics
Correct Answer: A,B,D
Rationale: A large goiter can compress the trachea, necessitating respiratory monitoring, head elevation, and a soft diet to ease swallowing.
Which characteristic symptom of the client's disorder would the nurse expect to find during an assessment?
- A. Polyphagia
- B. Polyuria
- C. Glycosuria
- D. Hyperglycemia
Correct Answer: B
Rationale: Diabetes insipidus is characterized by a deficiency of antidiuretic hormone, leading to excessive urination (polyuria) due to the kidneys' inability to conserve water.
The nurse is caring for the client with SIADH. Which interventions should the nurse plan to implement? Select all that apply.
- A. Obtain the weight near the same time each morning.
- B. Place the client on a fluid-restricted diet as prescribed.
- C. Prepare to give a 500-mL NaCl intravenous fluid bolus.
- D. Administer furosemide intravenously as prescribed.
- E. Monitor for hyperactive reflexes and heightened alertness.
Correct Answer: A,B,D
Rationale: Daily weights monitor fluid retention, fluid restriction treats hyponatremia, and furosemide addresses fluid overload in SIADH.
Which risk factor should the nurse expect to find in the client diagnosed with pancreatic cancer?
- A. Chewing tobacco.
- B. Low-fat diet.
- C. Chronic alcoholism.
- D. Exposure to industrial chemicals.
Correct Answer: C
Rationale: Chronic alcoholism is a well-established risk factor for pancreatic cancer, often linked to chronic pancreatitis, which predisposes to malignancy. Chewing tobacco is more associated with oral cancers, a low-fat diet is not a risk factor, and while industrial chemical exposure is a possible risk, it is less specific than alcoholism.