Nokea
Which statement by the client indicates a misunderstanding of the expected surgical outcome?
- A. My appearance will gradually become normal.
- B. I'll need to take replacement hormones.
- C. I'll need to see my physician regularly.
- D. The surgical incision will be inconspicuous.
Correct Answer: A
Rationale: In acromegaly, physical changes such as enlarged hands or facial features are typically irreversible, even after surgery.
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The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply.
- A. Maintain adequate ventilation.
- B. Assess fluid volume status.
- C. Administer intravenous potassium.
- D. Check for urinary ketones.
- E. Monitor intake and output.
Correct Answer: A,B,D,E
Rationale: Ventilation, fluid status, ketone checks, and I&O monitoring manage DKA’s acidosis, dehydration, and ketosis. Potassium is given only if low, not routinely.
In response to a question about timing of symptoms during the nursing history, when is the client most likely to describe that symptoms typically occur?
- A. After fasting more than 6 hours
- B. About 2 hours after eating a meal
- C. Late in the evening, before bedtime
- D. Early in the morning, before breakfast
Correct Answer: A
Rationale: Hyperinsulinism causes hypoglycemia, which is more likely after fasting due to excess insulin lowering blood glucose.
The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess?
- A. Moon face, buffalo hump, and hyperglycemia.
- B. Hirsutism, fever, and irritability.
- C. Bronze pigmentation, hypotension, and anorexia.
- D. Tachycardia, bulging eyes, and goiter.
Correct Answer: C
Rationale: Addison’s causes cortisol and aldosterone deficiency, leading to bronze pigmentation, hypotension, and anorexia. Other options describe Cushing’s, hyperthyroidism, or unrelated symptoms.
Which client statement indicates the need for further teaching about thyroidectomy postoperative care?
- A. I should support my neck when sitting up.
- B. I may need calcium supplements.
- C. I can resume normal activities immediately.
- D. I should report any voice changes.
Correct Answer: C
Rationale: Resuming normal activities immediately post-thyroidectomy is incorrect due to the risk of complications like bleeding or hypocalcemia.
The nurse teaches the client with newly diagnosed diabetes mellitus about the signs and symptoms of hypoglycemia. Which of the following should the nurse stress in teaching? Select all that apply.
- A. Sleepiness
- B. Shallow
- C. Thirst
- D. Hunger
- E. Diaphoresis
- F. Confusion
Correct Answer: D,E,F
Rationale: Hypoglycemia causes hunger, diaphoresis, and confusion due to low blood glucose affecting the brain and body.