Nokea
Which signs/symptoms should the nurse expect to assess in the 31-year-old client who has a sustained release of growth hormone (GH)?
- A. An enlarged forehead, maxilla, and face.
- B. A six (6)-inch increase in height of the client.
- C. The client complaining of a severe headache.
- D. A systolic blood pressure of 200 to 300 mm Hg.
Correct Answer: A
Rationale: Excess GH (acromegaly) causes facial and bone enlargement (e.g., forehead, maxilla). Height increase occurs pre-puberty, headaches are nonspecific, and extreme hypertension is unrelated.
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The client taking thyroid replacement hormone is hospitalized, and a thyroid replacement hormone is not prescribed. A week after being hospitalized, the nurse assesses that the client is becoming increasingly lethargic and has a decreased blood pressure, respiratory rate, temperature, and pulse. Which actions should be taken by the nurse? Place each nursing action in the order of priority.
- A. Warm the client
- B. Administer intravenous fluids
- C. Assist in ventilatory support
- D. Administer thyroxine as prescribed
Correct Answer: C,B,A,D
Rationale: Ventilatory support addresses decreased respiratory rate, IV fluids treat hypotension, warming prevents metabolic demand increase, and thyroxine corrects hypothyroidism.
The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem 'high risk for hyperglycemia related to noncompliance with the medication regimen.' Which statement is an appropriate short-term goal for the client?
- A. The client will have a blood glucose level between 90 and 140 mg/dL.
- B. The client will demonstrate appropriate insulin injection technique.
- C. The nurse will monitor the client's blood glucose levels four (4) times a day.
- D. The client will maintain normal kidney function with 30-mL/hr urine output.
Correct Answer: B
Rationale: Demonstrating correct insulin injection technique addresses noncompliance, a short-term, client-centered goal. Glucose levels and kidney function are outcomes, and nurse monitoring is not client-focused.
The client with DM is to receive insulin IV at 1.5 units per hour. The insulin bag contains 10 units of insulin in 100 mL of NS. The nurse should set the infusion pump to deliver how many milliliters per hour?
- A. 1.0 mL/hr
- B. 1.5 mL/hr
- C. 2.0 mL/hr
- D. 2.5 mL/hr
Correct Answer: B
Rationale: 10 units : 100 mL :: 1.5 units : X mL; 10X = 150; X = 1.5 mL/hr.
Based on the knowledge that clients with Cushing's syndrome heal slowly, which nursing measure is most appropriate during the client's postoperative period?
- A. Monitoring infusion of I.V. antibiotics
- B. Removing tape toward the incision site
- C. Increasing the client's dietary protein intake
- D. Covering the wound with gauze
Correct Answer: C
Rationale: Increased dietary protein supports tissue repair and healing in Cushing's syndrome.
The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse?
- A. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL.
- B. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia.
- C. The client with DKA who has multifocal premature ventricular contractions.
- D. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.
Correct Answer: C
Rationale: DKA with PVCs indicates cardiac instability, requiring an experienced nurse for complex monitoring and intervention. High glucose, hypoglycemia, and normal osmolarity are less critical.