Nokea
Which nursing assessment is most helpful in evaluating the status of a client with Addison's disease?
- A. Blood pressure
- B. Bowel sounds
- C. Breath sounds
- D. Heart sounds
Correct Answer: A
Rationale: Hypotension is a key sign of Addison's disease due to decreased aldosterone and cortisol.
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The client had a total pancreatectomy and splenectomy for cancer of the body of the pancreas. Which discharge instructions should the nurse teach? Select all that apply.
- A. Keep a careful record of intake and output.
- B. Use a stool softener or bulk laxative regularly.
- C. Use correct insulin injection technique.
- D. Take the pain medication before the pain gets too bad.
- E. Sleep with the head of the bed on blocks.
Correct Answer: B,C,D
Rationale: Stool softeners prevent constipation, insulin technique manages post-pancreatectomy diabetes, and proactive pain medication controls discomfort. I&O and elevated bed are unnecessary.
Which finding indicates a potential complication of thyroid crisis that the nurse should prioritize?
- A. Heart rate of 140 beats per minute
- B. Blood pressure of 120/80 mmHg
- C. Temperature of 98.6°F
- D. Respiratory rate of 16 breaths per minute
Correct Answer: A
Rationale: A heart rate of 140 beats per minute indicates severe tachycardia, a life-threatening complication of thyroid crisis requiring immediate intervention.
Which intervention is most appropriate to add to the client's care plan to the use of the personal bleeding after a subtotal thyroidectomy?
- A. Observe for signs of hypovolemic shock.
- B. Assess for dampness at the back of the client's neck.
- C. Remove the dressing to directly inspect the wound.
- D. Weigh all gauze dressings before and after changing.
Correct Answer: B
Rationale: Assessing for dampness at the back of the neck detects bleeding that may pool behind the client.
Immediately after surgery, the nurse assesses the client for bleeding. Where is the best location to assess for bleeding?
- A. The skull
- B. The nose
- C. The ear canal
- D. The tongue
Correct Answer: B
Rationale: Trans-sphenoidal hypophysectomy is performed through the nasal cavity, so bleeding is most likely to be observed in the nose.
An elderly woman has been recently diagnosed as having Type 2 diabetes. Which of the following complaints that she has is most likely to be related to the diagnosis of diabetes mellitus?
- A. Pruritus vulvae
- B. Cough
- C. Eructation
- D. Singultus
Correct Answer: A
Rationale: Pruritus vulvae is common in diabetes due to yeast infections from elevated glucose levels.