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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.
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Before the client is discharged, the physician orders lypressin (Diapid) to be administered p.r.n. When instructing the client about how to take this drug at home, the nurse tells the client to administer the drug when experiencing which sign or symptom?
- A. Increased thirst
- B. Onset of a headache
- C. Dark yellow urine
- D. A runny nose
Correct Answer: A
Rationale: Increased thirst is a symptom of diabetes insipidus indicating the need for lypressin to control fluid loss.
Which statement by the client about foot care indicates a need for further teaching?
- A. I need to inspect my feet daily.
- B. I should soak my feet each day.
- C. I need to wear shoes whenever I'm not sleeping.
- D. I need to schedule regular appointments with the podiatrist.
Correct Answer: B
Rationale: Soaking feet can lead to skin breakdown in diabetic clients; feet should be washed and dried carefully.
If the following foods are available, which one should the nurse recommend?
- A. Cheddar cheese
- B. Raw carrots
- C. Canned fruit
Correct Answer: A
Rationale: Cheddar cheese is high in sodium, which is beneficial for clients with Addison's disease to replace sodium loss.
Which assessment technique is most appropriate when checking for laryngeal nerve damage in a client who has had a thyroidectomy?
- A. Turning the client's head from side to side
- B. Occurifying the client's swallowing
- C. Looking for tracheal deviation
- D. Asking the client to say 'Ah'
Correct Answer: D
Rationale: Asking the client to say 'Ah' assesses vocal cord function, which can be affected by laryngeal nerve damage.
The nurse writes a problem of 'altered body image' for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented?
- A. Monitor blood glucose levels prior to meals and at bedtime.
- B. Perform a head-to-toe assessment on the client every shift.
- C. Use therapeutic communication to allow the client to discuss feelings.
- D. Assess bowel sounds and temperature every four (4) hours.
Correct Answer: C
Rationale: Therapeutic communication addresses body image concerns (e.g., moon face, weight gain) in Cushing’s, promoting coping. Glucose, assessments, and bowel sounds are unrelated.