Nokea
Which of the following assessment findings for a patient admitted with Graves' disease requires the most rapid intervention by the nurse?
- A. BP 166/100 mm Hg
- B. Bilateral exophthalmos
- C. Heart rate 136 beats/minute
- D. Temperature 40.4°C (104.7°F)
Correct Answer: D
Rationale: The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications.
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The nurse is planning teaching for a patient who was admitted with myxedema coma and diagnosed with hypothyroidism. Which of the following strategies is best for the nurse to use?
- A. Delay teaching until patient discharge.
- B. Ensure privacy by asking visitors to leave.
- C. Provide written handouts of all information.
- D. Offer multiple options for management of therapies.
Correct Answer: C
Rationale: Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Since the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.
The nurse is caring for a patient who has had a transsphenoidal resection of a pituitary tumour. Which of the following nursing actions should be included in the postoperative plan of care?
- A. Monitor urine output every hour.
- B. Palpate extremities for dependent edema.
- C. Check hematocrit hourly for first 12 hours.
- D. Obtain continuous pulse oximetry for 24 hours.
Correct Answer: A
Rationale: After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema and monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.
The nurse is caring for a patient who had radical neck surgery and develops hypoparathyroidism. Which of the following information should the nurse include in the teaching plan?
- A. Use of bisphosphonates to reduce bone demineralization.
- B. Include whole grains in the diet to prevent constipation.
- C. Take calcium supplementation to normalize serum calcium levels.
- D. Ensure a high fluid intake to decrease risk for nephrolithiasis.
Correct Answer: C
Rationale: Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole-grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.
The nurse is caring for a patient with hypertension who is diagnosed with a pheochromocytoma. Which of the following findings should the nurse monitor in the patient?
- A. Flushing
- B. Headache
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: B
Rationale: The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe pounding headache, diaphoresis, and abdominal or chest pain. Elevated blood glucose may also occur because of sympathetic nervous system stimulation. Bradycardia and flushing would not be expected.
The nurse is caring for a patient in a long-term care facility who has these medications prescribed. After the patient is diagnosed with hypothyroidism, which of the following medications should the nurse report to the health care provider?
- A. Docusate
- B. Diazepam
- C. Ibuprofen
- D. Cefoxitin
Correct Answer: B
Rationale: Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older persons. The nurse should discuss the diazepam with the health care provider before administration. The other medications may be given safely to the patient.