Nokea
A client is admitted for a series of Test s to verify the diagnosis of Cushing's syndrome.
Which of the following assessment findings, if observed by the nurse, would support this diagnosis?
- A. Buffalo hump, hyperglycemia, and hypernatremia.
- B. Nervousness, tachycardia, and intolerance to heat.
- C. Lethargy, weight gain, and intolerance to cold.
- D. Irritability, moon face, and dry skin.
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to Cushing's syndrome. (1) correct-Cushing's syndrome is characteristic of these assessments, as are weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) symptoms of hyperthyroidism (3) symptoms of hypothyroidism (myxedema) (4) symptoms of hypoparathyroidism
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A 30-year-old woman is receiving levothyroxine sodium (Synthroid) 0.1 mg PO daily.
Which of the following findings would indicate to the nurse that the client is getting favorable results from the medication?
- A. Decreased blood pressure.
- B. Increased urine output.
- C. Decreased pulse rate.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hypothyroidism. (1) characteristic of hypothyroidism, would indicate that medication is not working (2) correct-medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted (3) characteristic of hypothyroidism, would indicate that medication is not working (4) respiratory rate may or may not be affected by medication
A client with symptoms supportive of a diagnosis of Guillain-Barré syndrome.
The nurse knows that which of the following symptoms would be supportive of a diagnosis of Guillain-Barré syndrome?
- A. Hemiplegia, hypertension, tachycardia.
- B. Respiratory failure, flaccid paralysis, urinary retention.
- C. Peripheral edema, hypertension, pulmonary congestion.
- D. Diminished reflexes, pain, paresthesia.
Correct Answer: B
Rationale: Strategy: All parts of the answer choice must be correct in order for the answer to be correct. (1) relates to a CVA (2) correct-classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation (3) relates to pulmonary edema (4) relates to peripheral nerve problems
A client receiving HTZ (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
- A. A pear
- B. An apple
- C. An orange
- D. A banana
Correct Answer: D
Rationale: Hydrochlorothiazide is a diuretic that can cause potassium loss. Bananas are high in potassium, making them the best choice. Pears , apples , and oranges have less potassium.
A 14-year-old is going home with a permanent tracheostomy. Which comment by the child's mother indicates to the nurse that the parent needs more instruction?
- A. I need to ask the doctor how many times a day I can suction my child.'
- B. I will suction if my child cannot effectively cough up sputum.'
- C. I know my child will not need the same amount of suctioning every day.'
- D. I know I should only suction my child if it is really necessary.'
Correct Answer: A
Rationale: Asking for a fixed suctioning schedule suggests misunderstanding, as suctioning is PRN based on need, indicating a need for further instruction.
The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:
- A. above the clitoris.
- B. behind the vagina.
- C. between the clitoris and the vagina.
- D. between the vagina and the rectum.
Correct Answer: C
Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.