Nokea
Which of the following should be included in the nurse's preadministration assessment of a client about to receive adrenocorticotropic hormone (ACTH)? Select all that apply.
- A. Lung auscultation
- B. Mental status assessment
- C. Height
- D. Pulse
- E. Skin integrity assessment
Correct Answer: A,B,D,E
Rationale: Blood pressure, pulse, respiratory rate, temperature, weight, skin integrity assessment, mental status assessment, and lung auscultation should be included in the nurse's preadministration assessment of a client about to receive ACTH.
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A client is receiving corticosteroid therapy. Which nursing diagnosis would the nurse be least likely to identify for this client?
- A. Risk for Infection
- B. Disturbed Body Image
- C. Risk for Injury
- D. Deficient Fluid Volume
Correct Answer: D
Rationale: A client who is receiving corticosteroid therapy would be least likely to have a nursing diagnosis of Deficient Fluid Volume. Rather, Excess Fluid Volume would be more appropriate. Risk for Infection related to immunosuppression, Disturbed Body Image related to cushingoid effects, and Risk for Injury related to muscle atrophy and osteoporosis would be appropriate.
A nurse is educating a client and his family about vasopressin (DDAVP) for the treatment of diabetes insipidus. In addition to administration instructions, which of the following should the nurse discuss with the client and family? Select all that apply.
- A. Wearing a medical alert bracelet
- B. Monitoring the daily intake of fluids
- C. Avoiding sun exposure while using the drug
- D. Carrying extra doses with the client at all times
- E. Carrying liquids with the client at all times
Correct Answer: A,B,D,E
Rationale: In addition to administration instructions, the nurse should include the following: wear a medical alert bracelet, monitor the daily intake and output of fluids, avoid the use of alcohol, and carry extra doses and liquids with the client at all times.
A client has been prescribed glucocorticoids for the treatment of congenital adrenal hyperplasia. Which of the following assessments should the nurse perform for the client?
- A. Take and record vital signs every 4 to 8 hours.
- B. Test the serum electrolyte levels.
- C. Auscultate the abdomen and record the findings.
- D. Observe for signs of blanching of the skin.
Correct Answer: A
Rationale: When glucocorticoids are administered to the client, the nurse should take and record vital signs every 4 to 8 hours. The nurse need not perform assessments related to serum electrolyte levels, abdominal auscultation, or skin blanching. These are appropriate for a client receiving vasopressin therapy.
A client receiving gonadotropin therapy comes to the clinic for follow-up. Which of the following would the nurse immediately report to the primary health care provider? Select all that apply.
- A. Ascites
- B. Abdominal distention
- C. Abdominal pain
- D. Weight gain
- E. Irritability
Correct Answer: A,B,C
Rationale: The client is at risk for ovarian enlargement manifested by abdominal distention, pain, and ascites (with serious cases). The nurse would immediately notify the primary health care provider and the drug would be discontinued at the first sign of ovarian stimulation or enlargement. Weight gain and irritability would not need to be reported immediately.
A client is receiving corticosteroids at a health care facility. The client is also receiving digoxin as treatment for heart failure. The nurse understands that which of the following is a possibility due to the interaction of these two drugs?
- A. Increased risk for toxicity
- B. Decreased muscle function
- C. Increased risk of hyperkalemia
- D. Decreased serum corticosteroid levels
Correct Answer: A
Rationale: The nurse should observe for an increased risk for digoxin toxicity when corticosteroids are given with digoxin. Decreased muscle function, hyperkalemia, and decreased serum corticosteroid levels are not associated with the interaction.