Nokea
Which endocrine disorder should the nurse assess for in the client who has a closed head injury with increased intracranial pressure?
- A. Pheochromocytoma.
- B. Diabetes insipidus.
- C. Hashimoto’s thyroiditis.
- D. Gynecomastia.
Correct Answer: B
Rationale: Closed head injuries with increased intracranial pressure can impair the pituitary gland, leading to diabetes insipidus (DI) due to reduced antidiuretic hormone (ADH) secretion, causing polyuria and dehydration. Pheochromocytoma, Hashimoto’s, and gynecomastia are unrelated to head trauma.
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Which client problem has priority for the client diagnosed with acute pancreatitis?
- A. Risk for fluid volume deficit.
- B. Alteration in comfort.
- C. Imbalanced nutrition: less than body requirements.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in acute pancreatitis due to vomiting and third-spacing, risking hypovolemia. Pain, nutrition, and knowledge are secondary.
The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement?
- A. Assess for dehydration and monitor blood glucose levels.
- B. Assess for nausea and vomiting and weigh daily.
- C. Monitor potassium levels and encourage fluid intake.
- D. Administer vasopressin IV and conduct a fluid deprivation test.
Correct Answer: B
Rationale: Nausea/vomiting and daily weights monitor SIADH complications (e.g., hyponatremia, fluid overload). Dehydration is unlikely, potassium is less critical, and vasopressin worsens SIADH.
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.
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism?
- A. Increase the amount of fiber in the diet.
- B. Encourage a low-calorie, low-protein diet.
- C. Decrease the client's fluid intake to 1,000 mL/day.
- D. Provide six (6) small, well-balanced meals a day.
Correct Answer: D
Rationale: Six small, balanced meals meet the increased metabolic demands of hyperthyroidism. Fiber, low-calorie diets, and fluid restriction are inappropriate.
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.