Nokea
Which nursing care measure is essential because a client has exophthalmos?
- A. Administer artificial tears.
- B. Encourage the client to wear her glasses.
- C. Promote bed rest.
- D. Monitor her pulse rate every four hours.
Correct Answer: A
Rationale: Exophthalmos (bulging eyes) in hyperthyroidism causes dry eyes, requiring artificial tears to prevent corneal damage.
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The client develops SIADH secondary to a pituitary tumor. The client's assessment findings include thirst, weight gain, fatigue, and a serum sodium of 127 mEq/L. Which intervention, if prescribed, should the nurse implement to treat SIADH?
- A. Elevate the head of the bed 30 degrees
- B. Administer vasopressin intravenously (IV)
- C. Restrict fluids to 800 to 1000 mL per day
- D. Give 0.3% sodium chloride IV infusion
Correct Answer: C
Rationale: Fluid restriction to 800-1000 mL/day treats mild SIADH with serum sodium >125 mEq/L by raising sodium concentration.
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus?
- A. Serum sodium.
- B. Serum calcium.
- C. Urine glucose.
- D. Urine white blood cells.
Correct Answer: A
Rationale: Diabetes insipidus causes dilute urine, risking hypernatremia; serum sodium monitoring is critical. Calcium, urine glucose, and WBCs are unrelated.
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 is preparing to administer the following medications. Which medication should the nurse question administering?
- A. The thyroid hormone to the client who does not have a T3, T4 level.
- B. The regular insulin to the client with a blood glucose level of 210 mg/dL.
- C. The loop diuretic to the client with a potassium level of 3.3 mEq/L.
- D. The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.
Correct Answer: A
Rationale: Administering thyroid hormone without T3/T4 levels risks overtreatment, as levels confirm hypothyroidism. Insulin, diuretics, and digoxin are appropriate based on data.
How soon after administering the client's dose of regular insulin subcutaneously should the nurse assess for signs of hypoglycemia?
- A. 5 minutes later
- B. 30 minutes later
- C. 6 hours later
- D. 10 hours later
Correct Answer: B
Rationale: Regular insulin peaks around 2-4 hours, but early hypoglycemia can occur within 30 minutes, requiring assessment.