Nokea
Which sign/symptom indicates to the nurse the client is experiencing hypoparathyroidism?
- A. A negative Trousseau's sign.
- B. A positive Chvostek's sign.
- C. Nocturnal muscle cramps.
- D. Tented skin turgor.
Correct Answer: B
Rationale: A positive Chvostek’s sign (facial twitching) indicates hypocalcemia from hypoparathyroidism. Negative Trousseau’s, cramps, and turgor are less specific.
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A woman with a tumor of the adrenal cortex says to the nurse, 'Will I always look this ugly? I hate having a beard.' What is the best response for the nurse to make?
- A. After surgery, you will not develop any more symptoms, but the changes you have now will linger.'
- B. That varies from person to person. You should ask your physician.'
- C. After surgery, your appearance should gradually return to normal.'
- D. Electrolysis and plastic surgery should make your appearance normal.'
Correct Answer: C
Rationale: Post-adrenalectomy, hormonal imbalances causing symptoms like hirsutism should resolve, gradually normalizing appearance.
Which nursing care measure is essential because a client has exophthalmos?
- A. Administer artificial tears.
- B. Encourage the client to wear her glasses.
- C. Promote bed rest.
- D. Monitor her pulse rate every four hours.
Correct Answer: A
Rationale: Exophthalmos (bulging eyes) in hyperthyroidism causes dry eyes, requiring artificial tears to prevent corneal damage.
The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit?
- A. Kussmaul's respirations.
- B. Diarrhea and epigastric pain.
- C. Dry mucous membranes.
- D. Ketone breath odor.
Correct Answer: C
Rationale: HHNS causes severe dehydration, leading to dry mucous membranes. Kussmaul’s respirations and ketone odor are DKA-specific, and diarrhea/pain are less common.
Which action by the nurse provides the best data for monitoring the client's therapeutic response to sodium restriction?
- A. Monitoring sodium intake
- B. Measuring pedal edema
- C. Assessing skin turgor
- D. Weighing the client
Correct Answer: B
Rationale: Measuring pedal edema assesses fluid retention, a key indicator of sodium restriction response in Cushing's syndrome.
Which statement by the client provides the best evidence that the client understands the principle of an exchange list for meal planning?
- A. I can eat one serving from each category on the exchange list per day.
- B. I record the patient's disease of food in each category are equal to one another.
- C. The number of servings from the exchange list is unlimited.
- D. I need to use the exchange list to determine the nutrition in food.
Correct Answer: B
Rationale: The exchange list groups foods with similar nutritional content, allowing equivalent substitutions.