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ENDOCRINE NURSING -- PRACTICE QUESTIONS
A client is brought to the ED in an unresponsive state, and a dX of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would IMMEDIATELY pre... [Show More] pare to initiate which anticipated health care provider's prescription? a) endotracheal intubation b) 100 units of NPH insulin c) IV infusion of normal saline d) IV infusion of sodium bicarbonate - correct answer C An external insulin pump is prescribed for a client with DM and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? a) is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals b) continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels c) is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream d) gives a small continuous dose of short-duration insulin subQ-- and the client can self-administer a bolus with an additional dose from the pump before each meal - correct answer D A client with a diagnosis of DKA is being treated in the ED. Which findings would the nurse expect to note as confirming this diagnosis? SATA: a) increase in pH b) comatose state c) deep, rapid breathing d) decreased urine output e) elevated blood glucose level f) low plasma bicarbonate level - correct answer C, E, F The nurse teaches a client with DM about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? SATA: a) polyuria b) shakiness c) palpitations d) blurred vision e) lightheadedness f) fruity breath odor - correct answer B, C, E A client with DM demonstrates acute anxiety when first admitted to the hospital for the treatment of hyperglycemia. What is the MOST APPROPRIATE intervention to decrease the client's anxiety? a) administer a sedative b) convey empathy, trust, and respect toward the client c) ignore the signs and symptoms of anxiety so that they will soon disappear d) make sure that the client knows all the correct medical terms to understand what is happening - correct answer B The nurse provides instructions to a client newly dX with type I DM. The nurse recognizes accurate understanding of measures to prevent DKA when the client makes which statement? a) I will stop taking my insulin if I'm too sick to eat b) i will decrease my insulin dose during times of illness c) i will adjust my insulin dose according to the level of glucose in my urine d) i will notify my HCP if my blood glucose level is higher than 250 mg/dL - correct answer D A client is admitted to a hospital with a dX of DKA. The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which item? a) ampule of 50% dextrose b) NPH insulin subcutaneously c) IV fluids containing dextrose d) Phenytoin (Dilantin) for the prevention of seizures - correct answer C The nurse is monitoring a client newly dX with DM for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? a) polyuria b) diaphoresis c) hypertension d) increased pulse rate - correct answer A The nurse is preparing a plan of care for a client with DM who has hyperglycemia. The nurse places highest priority on which client problem? a) lack of knowledge b) inadequate fluid volume c) compromised family coping d) inadequate consumption of nutrients - correct answer B The home health nurse visits a client with a dX of type 1 DM. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a NEED FOR FURTHER TEACHING? a) i need to stop my insulin b) i need to increase my fluid intake c) i need to monitor my blood glucose every 3 to 4 hours d) i need to call the HCP because of these symptoms - correct answer A The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? a) lower the head of the bed b) test the drainage for glucose c) obtain a culture of the drainage d) continue to observe the drainage - correct answer B After several diagnostic tests, a client is dX with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? a) fatigue b) diarrhea c) polydipsia d) weight gain - correct answer C A client is admitted to an ED and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? a) warm the client b) maintain a patent airway c) administer thyroid hormone d) administer fluid replacement - correct answer B The nurse is caring for a client admitted to the ED with DKA. In the acute phase, the nurse plans for which priority intervention? a) correct the acidosis b) admin 5% dextrose IV c) apply a monitor for an EKG d) administer short-duration insulin IV - correct answer D A client with type 1 DM calls the nurse to report current episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise? a) the best time for me to exercise is after i eat b) the best time for me to exercise is after breakfast c) the beset time for me to exercise is mid to late afternoon d) the best time for me to exercise is after my morning snack - correct answer C The nurse is completing an assessment on a client who is being admitted for a dX workup for primary hyperparathyroidsim. which client complaint would be characteristic of this disorder? a) diarrhea b) polyuria c) polyphagia d) weight gain - correct answer B The nurse is caring for a post-op parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? a) laryngeal stridor b) abdominal cramps c) difficulty in voiding d) mild to moderate incisional pain - correct answer A A client is dX with pheochromocytoma. The nurse understands that this is a condition that has which characteristic? a) causes profound hypotension b) is manifested by severe hypoglycemia c) is not curable and is treated symptomatically d) causes the release of excessive amounts of catecholamines - correct answer D The nurse is monitoring a client who was dX with type 1 DM and is being treated with NPH and regular insulin. Which client complaint(s) would alert the nurse to the presence of a possible hypoglycemic reaction? SATA: a) tremors b) anorexia c) irritability d) nervousness e) hot, dry skin f) muscle cramps - correct answer A, C, D The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? a) a coagulation time of 5 mins b) a urinary output of 50 mL/hour c) a blood urea nitrogen level of 20 mg/dL d) a heart rate that is 90 beats per minute and irregular - correct answer D The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? a) it results from an oversecretion of insulin b) it results from an undersecretion of corticotropic hormones c) it results from an undersecretion of mineralocorticoid hormones d) it results from an increased pituitary secretion of adrenocorticotropic hormone - correct answer D The nurse performs a physical assessment on a client with type 2 DM. Findings include a fasting blood glucose level of 120 mg/dL, temperature of 101 F, pulse of 88 bpm, respirations of 22 breaths/min, and BP of 100/72. Which finding would be of MOST concern for the nurse? a) pulse b) respiration c) temperature d) BP - correct answer C The nurse is interviewing a client with type 2 DM. Which statement by the client indicates an understanding of the treatment for this disorder? a) i take oral insulin instead of shots b) by taking these meds, i am able to eat more c) when i become ill, i need to increase the number of pills i take d) the meds im taking help release the insulin i already make - correct answer D The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? a) i will need to limit the amount of protein in my diet b) i should eat foods that have a lot of potassium in them c) i am fortunate that i can eat all the salty foods i enjoy d) i am fortunate that i donot need to follow any special diet - correct answer B The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carb-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client's room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time? a) call a code to obtain needed assistance immediately b) obtain a capillary blood glucose level and perform a focused assessment c) ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining 15 to 30 g of carbohydrate snack for the client to eat d) stay with the client and ask the UAP to call the HCP for a prescription for IV 50% dextrose - correct answer B The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? a) vital signs b) intake and output c) blood urea nitrogen results d) urine for glucose and ketones - correct answer A The nurse is preparing a client with a new dX of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this dX? SATA: a) tremors b) weight loss c) feeling cold d) loss of body hair e) persistent lethargy f) puffiness of the face - correct answer C, D, E, F A client has just been admitted to the nursing unit following throidectomy. Which assessment is the priority for this client? a) hypoglycemia b) level of hoarseness c) respiratory distress d) edema at the surgical site - correct answer C A client has been dX with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? SATA: a) fever b) nausea c) lethargy d) tremors e) confusion f) bradycardia - correct answer A, B, D, E The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? a) withdraws the NPH insulin first b) withdraws the regular insulin first c) injects air into NPH insulin vial first d) injects an amount of air equal to the desired dose of insulin into each vial - correct answer A The home care nurse visits a client recently dX with diabetes mellitus who is taking humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? a) freeze the insulin b) refrigerate the insulin c) store the insulin in a dark, dry place d) keep the insulin at room temperature - correct answer B Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication? a) alcohol b) organ meats c) whole-grain cereals d) carbonated beverages - correct answer A Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. The nurse reviews the client's medical record and should question the prescription if which data is noted in the client's history? a) insomnia b) neuralgia c) use of nitroglycerin d) use of multivitamins - correct answer C The health care provider prescribes exenatide (Byetta) for a client with type 1 DM who takes insulin. The nurse should plan to take which most appropriate intervention? a) withhold the medication and call the HCP, questioning the prescription for the client b) administer the medication within 60 mins b4 the morning and evening meal c) monitor the client for the GI side effects after administering the med d) withdraw the insulin from the prefilled pen into an insulin syringe to prep for administration - correct answer A A client taking Humulin NPH insulin and rugular insulin every morning. The nurse should provide which instructions to the client? SATA: a) hypoglycemia may be experienced before dinnertime b) the insulin dose should be decreased if illness occurs c) the insulin should be administered at room temp d) the insulin vial needs to be shaken vigorously to break up the precipitates e) the NPH insulin should be drawn into the syringe first, then the regular insulin - correct answer A, C The home health care nurse is visiting a client who was recently dX with type 2 DM. the client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these meds. The nurse should provide which instructions to the client? SATA: a) diarrhea may occur secondary to the metformin b) the repaglinide is not taken if a meal is skipped c) the repaglinide is taken 30 mins before eating d) a simple sugar food item is carried and used to treat mild hypoglycemia episodes e)metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide. f) muscle pain is an expected effect of metformin and may be treated with acetaminophen (tylenol) - correct answer A, B, C, D The community health nurse visits a client at home. Prednisone, 10 mg orally daily, has been prescribed for the client and the nurse teaches the client about the med. Which statement, if made by the client, indicates that further teaching is necessary? a) i can take aspirin or my antihistamine if i need it b) i need to take the med every day at the same time c) i need to avoid coffee, tea, cola, and cock in my diet d) if i gain more than 5 lbs in a week, i will call my HCP - correct answer A A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this med? SATA: a) administer methimazole with food b) place the client on a low-cal, low-protein diet c) assess the client for unexplained bruising or bleeding d) instruct the client to report side/adverse effects such as sore throat, fever, or headaches e) use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration - correct answer A, C, D The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this med? SATA: a) insomnia b) weight loss c) bradycardia d) constipation e) mild heat intolerance - correct answer A, B, E The nurse provides instructions to a client who is taking levothyroxine (Synthroid). The nurse should tell the client to take the med at which time? a) with food b) at lunchtime c) on an empty stomach d) at bedtime with a snack - correct answer C The nurse provides medication instructions to a client who is taking levothyroxine (Synthroid) and should tell the client to notify the HCP if which problem occurs? a) Fatigue b) Tremors c) Cold intolerance d) Excessively dry skin - correct answer B The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which condition? a) myxedema b) graves disease c) addison's disease d) cushing's syndrome - correct answer B The nurse is instructing a client regarding intradermal desmopressin (DDAVP). The nurse should tell the client that which occurence is a side effect of the medication? a) headache b) vulval pain c) runny nose d) flushed skin - correct answer C A daily dose of Prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the med and should instruct the client that which time is BEST to take this med? a) at noon b) at bedtime c) early morning d) any time, at the same time, each day - correct answer C Prednisone is prescribed for a client with DM who is taking Humulin NPH insulin daily. Which prescription change does the nurse anticipate during therapy with the prednisone? a) an additional dose of prednisone daily b) a decreased amount of humulin NPH insulin daily c) an increased amount of daily Humulin NPH insulin d) the addition of an oral hypoglycemic medication daily - correct answer C A client with DM visits a health care clinic. The client's DM previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? a) prednisone b) phenelzine (Nardil) c) Atenolol (Tenormin) d) Allopurinol (Zyloprim) - correct answer A On the day of discharge, the client newly dX with type 1 diabetes says to the nurse, "tell me again, what should I do if I develop a fever?" Which response is best? a) increase your caloric intake and decrease your insulin dosage. b) discontinue taking insulin until after your febrile state has passed c) continue taking insulin as prescribed d) contact your physician to have the insulin dose adjusted - correct answer C Need for insulin is increased with any concurrent illness, especially an infection; presence of a (fever?!), inability to ingest food, nausea, vomiting, diarrhea, and erratic blood glucose levels are all reasons for an immediate call to the physician (should they occur when the patient continues taking their insulin as prescribed) The nurse understands that which type of insulin has the longest duration of action? a) Regular b) Glargine c) NPH d) Humulin R - correct answer B onset of Glargine insulin: 3 to 4 hours Small amount has NO peak; duration = 24 hours *NPH also has a duration of 24 hours but unlike Glargine, it DOES have a peak (4-12 hours) the nurse in the outpatient clinic cares for a client with the diagnosis of Cushing's disease. The nurse should expect to observe which symptom? a) weight loss b) thin legs and arms c) hypoglycemia d) hypotension - correct answer B even though there is truncal obesity, clients will have thin arms and legs due to MUSCLE WASTING Patients will also have edema, purple striations, and a decreased resistance to infection [Show Less]
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ENDOCRINE DISORDER NCLEX QUESTIONS
A patient suspected of having acromegaly has an elevated plasma growth hormone level. In acromegaly, the nurse would also expect the patient's diagnostic r... [Show More] esults to include a. hyperinsulinemia b. a plasma glucose of less than 70 c. decreased growth hormone levels with an oral glucose challenge test d. a serum sometomedin C (insulin-like growth-factor) of more than 300 - correct answer d. a serum somatomedin C (Insulin-like-growth-factor) of more than 300 (rationale- a normal response to growth hormone secretion is stimulation of the liver to produce somatomedin C which stimulates growth of bones and soft tissue. The increased levels of somatomedin C normally inhibit growth hormone, but in acromegaly the pituitary gland secretes GH despite elevated somatomedin C levels.) During assessment of the patient with acromegaly, the nurse would expect the patient to report a. infertility b. dry, irritated skin c. undesirable changes in appearance d. an increase in height of 2 to 3 inches per year - correct answer c. undesirable changes in appearance (Rationale- the increased production of growth hormone in acromegaly causes an increase in thickness and width of bones and enlargement of soft tissues, resulting in marked changes in facial features, oily and coarse skin, and speech difficulties. Height is not increased in adults with growth hormone excess because the epiphyses of the bones are closed, and infertility is not a common finding because growth hormone is usually the only pituitary hormone involved in acromegaly.) A patient with acromegaly is treated with a transphenoidal hypophysectomy. Postoperatively, the nurse a. ensures that any clear nasal drainage is tested for glucose b. maintains the patient flat in bed to prevent cerebrospinal fluid leak c. assists the patient with toothbrushing Q4H to keep the surgical area clean d. encourages deep breathing and coughing to prevent respiratory complications - correct answer a. ensures that any clear nasal drainage is tested for glucose (Rationale- a transphenoidal hypophysectomy involves entry into the sella turcica through an incision in the upper lip and gingiva into the floor of the nose and the sphenoid sinuses. Postoperative clear nasal drainage with glucose content indicates CSF leakage from an open connection to the brain, putting the patient at risk for meningitis. After surgery, the patient is positioned with the head elevated to avoid pressure on the sella turcica, coughing and straining are avoided to prevent increased ICP and CSF leakage, and although mouth care is required Q4H toothbrushing should not be performed for 7-10post sx.) During care of a patient with syndrome of inappropriate ADH (SIADH), the nurse should a. monitor neurologic status Q2H or more often if needed b. keep the head of the bed elevated to prevent ADH release c. teach the patient receiving treatment with diuretics to restrict sodium intake d. notify the physician if the patient's blood pressure decreases more than 20mmHg from baseline - correct answer a. monitor neurologic status Q2H or more often if needed Rationale- the patient with SIADH has marked dilution hyponatremia and should be monitored for decreased neurologic function and convulsions every 2 hours. ADH release is reduced by keeping the head of the bed flat to increase left atrial filling pressure, and sodium intake is supplemented because of hyponatremia and sodium loss caused by diuretics. A reduction in blood pressure indicates a reduction in total fluid volume and is an expected outcome of treatment.) A patient with SIADH is treated with water restriction and administration of IV fluids. The nurses evaluates that treatment has been effective when the patient experiences a. increased urine output, decreased serum sodium, and increased urine specific gravity b. increased urine output, increased serum sodium, and decreased urine specific gravity c. decreased urine output, increased serum sodium, and decreased urine specific gravity d. decreased urine output, decreased serum sodium, and increased urine specific gravity - correct answer b. increased urine output, increased serum sodium, and decreased urine specific gravity (rationale- the patient with SIADH has water retention with hyponatremia, decreased urine output and concentrated urine with high specific gravity. improvement in the patient's condition reflected by increased urine output, normalization of serum sodium, and more water in the urine, decreasing the specific gravity.) In a patient with central diabetes insipidus, administration of aqueous vasopressin during a water deprivation test will result in a a. decrease in body weight b. increase in urinary output c. decrease in blood pressure d. increase in urine osmolality - correct answer d. increase in urine osmolality (rationale- a patient with DI has a deficiency of ADH with excessive loss of water from the kidney, hypovolemia, hypernatreamia, and dilute urine with a low specific gravity. When vasopressin is administered, the symptoms are reversed, with water retention, decreased urinary output that increases urine osmolality, and an increase in blood pressure.) A patient with DI is treated with nasal desmopression. The nurse recognize that the drug is not having an adequate therapeutic effect the the patient experiences a. headache and weight gain b. nasal irritation and nausea c. a urine specific gravity of 1.002 d. an oral intake greater than urinary output - correct answer c. a urine specific gravity of 1.002 (rationale- normal urine specific gravity is 1.003 to 1.030, and urine with a specific gravity of 1.002 is very dilute, indicating that there continues to be excessive loss of water and that treatment of DI is inadequate. H/A, weight gain, and oral intake greater the urinary output are signs of volume excess that occur with overmedication. Nasal irritation & nausea may also indicate overmedication.) When caring for a patient with nephrogenic DI, the nurse would expect treatment to include a. fluid restriction b. thiazide diuretics c. a high-sodium diet d. chlorpropamide (DIabinese) - correct answer b. thiazide diuretics (Rationale- in nephrogenic Di the kidney is unable to respond to ADH, so vasopressin or hormone analogs are not effective. Thiazide diuretics slow the glomerular filtration rate in the kidney and produce a decrease in urine output. Low-sodium diets are also thought to decrease urine output. Fluids are not restricted, because the patient could become easily dehydrated.) A patient with Grave's dz asks the nurse what caused the disorder. The best response by the nurse is a. "The cause of Grave's disease is not known, although it is thought to be genetic." b. "It is usually associated with goiter formation from an iodine deficiency over a long period of time." c. "Antibodies develop against thyroid tissue and destroy it, causing a deficiency of thyroid hormones" d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones." - correct answer d. "In genetically susceptible persons antibodies form that attack thyroid tissue and stimulate overproduction of thyroid hormones." (rationale- The antibodies present in Graves' disease that attack thyroid tissue cause hyperplasia of the gland and stimulate TSH receptors on the thyroid and activate the production of thyroid hormones, creating hyperthyroidism. The disease is not directly genetic, but individuals appear to have a genetic susceptibility to become sensitized to develop autoimmune antibodies. Goiter formation from insufficient iodine intake is usually associated with hypothyroidism.) A patient is admitted to the hospital in thyrotoxic crisis. On physical assessment of the patient, the nurse would expect to find a. hoarseness and laryngeal stridor b. bulging eyeballs and arrhythmias c. elevated temperature and signs of heart failure d. lethargy progressing suddenly to impairment of consciousness - correct answer c. elevated temperature and signs of heart failure (rationale- a hyperthyroid crisis results in marked manifestations of hyperthyroidism, with fever tachycardia, heart failure, shock, hyperthermia, agitation, N/V/D, delirium, and coma. Although exophthalmos may be present in the patient with Gravs' dz, it is not a significant factor in hyperthyroid crisis. Hoarsness and laryngeal stridor are characteristic of the tetany of hypoparathyroidism, and lethargy progressing to coma is characteristic of myxedema coma, a complication of hypothyroidism. Preoperative instructions for the patient scheduled for a subtotal thyroidectomy includes teaching the patient a. how to support the head with the hands when moving b. that coughing should due avoided to prevent pressure on the incision c. that the head and neck will need to remain immobile until the incision heals d. that any tingling around the lips or in the fingers after surgery is expected and temporary - correct answer a. how to support the head with the hands when moving (rationale- to prevent strain on the suture line postoperatively, the head must be manually supported while turning and moving in bed, but range-of-motion exercise for the head and neck are also taught preoperatively to be gradually implemented after surgery. There is no contraindication for coughing and deep breathing, and they should be carrier out postoperatively. Tingling around the lips or fingers is a sign of hypocalcemia, which may occur if the parathyroid glands are inadvertently removed during surgery, and should be reported immediately.) When providing discharge instructions to a patient following a subtotal thyroidectomy, the nurse advises the patient to a. never miss a daily dose of thyroid replacement therapy b. avoid regular exercise until thyroid function is normalized c. avoid eating foods such as soybeans, turnips, and rutabagas d. use warm salt water gargles several times a day to relieve throat pain - correct answer c. avoid eating foods such as soybeans, turnips, and rutabagas (Rationale- when a patient has had a subtotal thyroidectomy, thyroid replacement therapy is not given, because exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of thyroid tissue regeneration. However, the patient should avoid goitrogens, foods that inhibit thyroid, such as soybeans, turnips, rutabagas, and peanut skins. REgular exercise stimulates the thyroid gland and is encourage. Salt water gargles are used for dryness and irritation of the mouth and throat following radioactive iodine therapy.) Causes of primary hypothyroidism in adults include a. malignant or benign thyroid nodules b. surgical removal or failure of the pituitary gland c. surgical removal or radiation of thyroid gland d. autoimmune-induced atrophy of the gland - correct answer d. autoimmune-induced atrophy of the gland (rationale- both Graves disease and Hasimotos thyroiditis are autoimmune disorders that eventually destroy the thyroid gland, leading to primary hypothyroidism. Thyroid tumors most often result in hyperthyroidism. Secondary hypothyroidism occurs as a result of pituitary failure, and iatrogenic hypothyroidism results from thyroidectomy or radiation of the thyroid gland.) Physical changes of hypothyroidism that must be monitored when replacement therapy is started include a. achlorhydria and constipation b. slowed mental processes and lethargy c. anemia and increased capillary fragility d. decreased cardiac contractility and coronary atherosclerosis - correct answer d. decreased cardiac contractility and coronary atherosclerosis (rationale- hypothyroidism affects the heart in many ways, causing cardiomyopathy, coronary atherosclerosis, bradycardia, pericardial effusions, and weakened cardiac contractility. when thyroid replacement therapy is started, myocardial oxygen consumption is increased and the resultant oxygen demand may cause angina, cardiac arrhythmias, and heart failures. It is important to monitor patients with compromised cardiac status when starting replacement therapy.) A patient with hypothyroidism is treated with Synthroid. When teaching the patient about the therapy, the nurse a. explains that caloric intake must be reduced when drug therapy is started b. provides written instruction for all information related to the medication therapy c. assures the patient that a return to normal function will occur with replacement therapy d. informs the patient that medications must be taken until hormone balance is reestablished - correct answer b. provides written instruction for all information related to the medication therapy (rationale- because of the mental sluggishness, inattentiveness, and memory loss that occur with hypothyroidism, it is important to provide written instructions and repeat information when teaching the patient. Caloric intake can be increased when drug therapy is started, because of an increased metabolic rate, and replacement therapy must be taken for life. Although most patients return to a normal state with treatment, cardiovascular conditions and psychoses may persist.) An appropriate nursing intervention for the patient with hyperparathyroidism is to a. pad side rails as a seizure precaution b. increase fluid intake to 3000 to 4000ml/day c. maintain bed rest to prevent pathologic fractures d. monitor the patient for Trousseau's phenomenon or Chvostek's sign - correct answer b. increase fluid intake to 3000 to 4000ml/day (Rationale-A high fluid intake is indicated in hyperparathyroidism to dilute hypercalcemia and flush the kidneys so that calcium stone formation is reduced.) When the patient with parathyroid disease experiences symptoms of hypocalcemia, a measure that can be used to temporarily raise serum calcium levels is to a. administer IV normal saline b. have the patient rebreathe in a paper bag c. administer Lasix as ordered d. administer oral phosphorous supplements - correct answer b. have the patient rebreathe in a paper bag (rationale- rebreathing in a paper bag promotes carbon dioxide retention in the blood, which lowers pH and creates an acidosis. An academia enhances the solubility and ionization of calcium, increasing the proportion of total body calcium available in physiologically active form and relieving the symptoms of hypocalcemia. Saline promotes calcium excretion, as does Lasix. Phosphate levels in the blood are reciprocal to calcium and an increase in phosphate promotes calcium excretion.) A patient is admitted to the hospital with a diagnosis of Cushing syndrome. On physical assessment of the patient, the nurse would expect to find a. HTN, peripheral edema, and petechiae b. weight loss, buffalo hump, and moon face with acne c. abdominal and buttock striae, truncal obesity, and hypotension d. anorexia, signs of dehydration, and hyper pigmentation of the skin - correct answer a. HTN, peripheral edema, and petechiae (rationale- The effects of glucocorticoid excess include weight gain from accumulation and redistribution of adipose tissue, sodium and water retention, glucose intolerance, protein wasting, loss of bone structure, loss of collagen, and capillary fragility. Clinical manifestations of corticosteroid deficiency include hypotension, dehydration, weight loss, and hyperpigmentation of the skin.) To prevent complications in the patient with Cushing syndrome, the nurse monitors the patient for a. hypotension b. hypoglycemia c. cardiac arrhythmias d. decreased cardiac output - correct answer c. cardiac arrhythmias (rationale- electrolyte changes that occur in Cushing syndrome include sodium retention and potassium excretion by the kidney, resulting in hypokalemia, which may lead to cardiac arrhythmias or arrest. Hypotension, hypoglycemia, and decreased cardiac strength and output are characteristic of adrenal insufficiency.) A patient is scheduled for bilateral adrenalectomy. During the postoperative period, the nurse would expect administration of corticosteroids to be a. reduced to promote wound healing b. withheld until symptoms of hypocortisolism appear c. increased to promote an adequate response to the stress of surgery d. reduced because excessive hormones are released during surgical manipulation of the glands - correct answer c. increased to promote an adequate response to the stress of surgery (rationale- although the patient with Cushing syndrome has excess corticosteroids, removal of the glands and the stress of surgery require that high doses of cortisone be administered postoperatively for several days. The nurse should monitor the patient postoperatively to detect whether large amounts of hormones were released during surgical manipulation and to ensure the healing is satisfactory.) A patient with Addison's disease comes to the emergency department with complaints of N/V/D, and fever. The nurse would expect collaborative care to include a. parenteral injections of ACTH b. IV administration of vasopressors c. IV administration of hydrocortisone d. IV administration of D5W with 20mEq of KCl - correct answer c. IV administration of hydrocortisone (rationale- vomiting and diarrhea are early indicators of addisonian crisis and fever indicates an infection, which s causing additional stress for the patient. treatment of a crisis requires immediate glucocorticoid replacement, and IV hydrocortisone, fluids, sodium and glucose are necessary for 24hours. Addison's disease is a primary insufficiency of the adrenal gland, and ACTH is not effective, nor would vasopressors be effective with the fluid deficiency of Addison's. Potassium levels are increased in Addison's dz, and KCl would be contraindicated.) The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when a. the patient appears alert and oriented b. the patient's urinary output has increased c. pulmonary edema is reduced as evidenced by clear lung sounds d. laboratory tests reveal serum elevations of K and glucose and a decrease in sodium - correct answer a. the patient appears alert and oriented (rationale- confusion, irritability, disorientation, or depressioni s often present in the patient with Addison's dz, and a positive response to therapy would be indicated by a return to alertness and orientation. Other indication of response to therapy would be a decreased urinary output, decreased serum potassium, and increased serum sodium and glucose. The patient with Addison's would be very dehydrated and volume-depleted and would not have pulmonary edema.) The most important nursing intervention during the medical and surgical treatment of the patient with a pheochromocytoma is a. administering IV fluids b. monitoring blood pressure c. monitoring I&O and daily weights d. administering B-adrenergic blocking agents - correct answer b. monitoring blood pressure38 (rationale- a pheochromocytoma is a catecholamine-producing tumor of the adrenal medulla, which may cause severe, episodic HTN; severe, pounding headache; and profuse sweating. Monitoring for dangerously high BP before surgery is critical, as is monitoring for BP fluctuation during medical and surgical tx.) When caring for a patient with primary hyperaldosteronism, the nurse would question a physician's order for the use of a. Lasix b. amiloride (midamor) c. spironolactone (aldactone) d. aminoglutethimide (cytadren) - correct answer a. Lasix37 (rationale- hyperaldosteronism is an excess of aldosterone, which is manifested by sodium and water retention and potassium excretion. Lasix is a potassium-wasting diuretic that would increase the potassium deficiency. Aminoglutethimide blocks aldosterone synthesis; amiloride is apotassium-sparing diuretic; and spironolactone blocks mineralocorticoid receptors in the kidney, increasing secretion of sodium and water and retention of potassium.) [Show Less]
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ENDOCRINE NCLEX QUESTIONS B
The nurse caring for a patient who recently underwent removal of a pituitary adenoma via the transphenoidal approach knows that which of the following rout... [Show More] ine post-operative interventions will be contraindicated for this patient: A.Turn every 2 hours B.Cough and deep breath C.Ambulation D.HOB 30 degrees - correct answer Answer: B The nurse caring for a patient who recently underwent removal of a pituitary adenoma via the transphenoidal approach knows that a common complication with this surgery is a headache. In order to prevent this complication the nurse will: A.Provide pain medication routinely B.Keep the patient in the supine position C.Assess VS every 2 hours D.Keep the patient's HOB at 30 degrees - correct answer Answer. D The nurse caring for a patient admitted with an ADH secreting lung cancer would anticipate which lab finding: A. Serum sodium 150 B. Serum osmolality elevated C. Urine specific gravity 1.002 D. Serum sodium 125 - correct answer D Common nonspecific manifestations that may alert the nurse to endocrine dysfunction include: A. Goiter and alopecia B. Exophthalmos and tremors C. Weight loss, fatigue, depression D. Polyuria, polydipsia, and polyphagia - correct answer C A patient with diabetes insipidus is treated with DDAVP. The nurse determines that the drug is not having an adequate therapeutic effect when the patient experiences: A. Headache and weight gain B. Nasal irritation and nausea C. A urine specific gravity of 1.002 (1.003-1.030) D. Oral intake greater than urinary output - correct answer Answer: C The nurse caring for a patient admitted with SIADH can anticipate which of the following physician orders: A.0.45% NS at 100 ml/hr B.D5W at 100 ml/hr C.Fluid restriction of 1000 ml/day D.DDAVP IVP - correct answer Answer: C A nurse is caring for a patient after hypophysectomy. The nurse notices clear nasal drainage from the patient's nostril. The initial nursing action would be to: A. Lower the head of the bed B. Test the drainage for glucose C. Obtain a culture of the drainage D. Continue to observe the drainage - correct answer Answer: B When obtaining subjective data from a patient during assessment of the endocrine system, the nurse asks specifically about: A. Energy level B. Intake of vitamin C C. Employment history D. Frequency of sexual intercourse - correct answer Answer: A A potential adverse effect of palpating the thyroid gland is: A. Carotid artery obstruction B. Damage to the cricoid cartilage C. Release of excessive thyroid hormone D. Hoarseness from pressure on the laryngeal nerve - correct answer Answer: C The normal response to increased serum osmolality is the release of: A. Aldosterone from the adrenal cortex, which stimulates sodium excretion by the kidney. B. ADH from the posterior pituitary gland, which stimulates the kidney to reabsorb water. C. Mineralocorticoids from the adrenal gland, which stimulates the kidney to excrete potassium. D. Calcitonin from the thyroid gland, which increases bone resorption and decreases serum calcium levels. - correct answer Answer: B Following a hypophysectomy for acromegaly, postoperative nursing care should focus on: A. Frequent monitoring of serum and urine osmolarity B. Parenteral administration of a GH-receptor antagonist C. Keeping the patient in a recumbent position at all times D. Patient education regarding the need for lifelong ACTH, TSH, FSH, LH hormone replacement - correct answer A The health care provider prescribes Levothyroxine for a patient with hypothyroidism. Following teaching regarding this medication, the nurse determines that further teaching is needed when the patient says: A. "I can expect the medication dose may need to be increased" B. "I can expect to return to normal function with the use of this drug" C. "I will only need to take this medication until my symptoms are improved" D. I will report any chest pain or difficulty breathing to the doctor right away" - correct answer Answer: C Following thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops: A. Muscle weakness and weight loss B. Hyperthermia and severe tachycardia C. Hypertension and difficulty swallowing D. Laryngeal stridor and tingling in the hands and feet - correct answer Answer: D Manifestations of endocrine problems in the older adult that are commonly attributed to the aging process are: (Select all that apply) A. tremors B. fatigue C. fluid retention D. mental impairment - correct answer Answer: B and D The nurse is caring for a patient with Grave's disease and assessment reveals exophthalmos. Which of the following interventions are indicated to prevent injury to the eye: (Select all that apply) A. Elevate HOB B. Apply eye patches during sleep C. Have patient blink frequently D. Lubricating eyedrops - correct answer A and D Important Nursing interventions when caring for a patient with Cushing syndrome include (select all that apply) A. restricting protein intake. B. monitoring blood glucose levels. C. administering medication in equal doses. D. protecting patient from exposure to infection. - correct answer B and D The nurse teaches the patient that the best time to take corticosteroids for replacement purposes is A. once a day at bedtime. B. every other day on awakening. C. on arising and in the late afternoon. D. at consistent intervals every 6-8 hours. - correct answer C [Show Less]
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ENDOCRINE NCLEX QUESTIONS
1. An agitated, confused female client arrives in the emergency department. Her history includes type 1 diabetes mellitus, hypertension, and angina pectori... [Show More] s. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, nurse Lily teaches the client to treat hypoglycemia by ingesting: a. 2 to 5 g of a simple carbohydrate. b. 10 to 15 g of a simple carbohydrate. c. 18 to 20 g of a simple carbohydrate. d. 25 to 30 g of a simple carbohydrate. - correct answer B. To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia. 2. A female adult client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, nurse Julia formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add? a. Related to bone demineralization resulting in pathologic fractures b. Related to exhaustion secondary to an accelerated metabolic rate c. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces d. Related to tetany secondary to a decreased serum calcium level - correct answer A. Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn't accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn't associated with tetany. 3. Nurse John is assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: a. Encourage the client to ask questions about personal sexuality. b. Provide time for privacy. c. Provide support for the spouse or significant other. d. Suggest referral to a sex counselor or other appropriate professional. - correct answer D. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling. 4. During a class on exercise for diabetic clients, a female client asks the nurse educator how often to exercise. The nurse educator advises the clients to exercise how often to meet the goals of planned exercise? a. At least once a week b. At least three times a week c. At least five times a week d. Every day - correct answer B. Diabetic clients must exercise at least three times a week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once a week wouldn't achieve these goals. Exercising more than three times a week, although beneficial, would exceed the minimum requirement. 5. Nurse Oliver should expect a client with hypothyroidism to report which health concerns? a. Increased appetite and weight loss b. Puffiness of the face and hands c. Nervousness and tremors d. Thyroid gland swelling - correct answer B. Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter). 6. A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect? a. Dysuria b. Leg cramps c. Tachycardia d. Blurred vision - correct answer C. Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine. 7. A 67-year-old male client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, nurse Richard would suspect which of the following disorders? a. Diabetes mellitus b. Diabetes insipidus c. Hypoparathyroidism d. Hyperparathyroidism - correct answer D. Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria. 8. When caring for a male client with diabetes insipidus, nurse Juliet expects to administer: a. vasopressin (Pitressin Synthetic). b. furosemide (Lasix). c. regular insulin. d. 10% dextrose. - correct answer A. Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus. 9. The nurse is aware that the following is the most common cause of hyperaldosteronism? a. Excessive sodium intake b. A pituitary adenoma c. Deficient potassium intake d. An adrenal adenoma - correct answer D. An autonomous aldosterone-producing adenoma is the most common cause of hyperaldosteronism. Hyperplasia is the second most frequent cause. Aldosterone secretion is independent of sodium and potassium intake as well as of pituitary stimulation. 10. A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, nurse Sharmaine would be most accurate in stating: a. "The test needs to be repeated following a 12-hour fast." b. "It looks like you aren't following the prescribed diabetic diet." c. "It tells us about your sugar control for the last 3 months." d. "Your insulin regimen needs to be altered significantly." - correct answer C. The glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting period before blood is drawn. The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin coverage. 11. Following a unilateral adrenalectomy, nurse Betty would assess for hyperkalemia shown by which of the following? a. Muscle weakness b. Tremors c. Diaphoresis d. Constipation - correct answer A. Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and occurs from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia. 12. Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus? a. antidiuretic hormone (ADH). b. thyroid-stimulating hormone (TSH). c. follicle-stimulating hormone (FSH). d. luteinizing hormone (LH). - correct answer A. ADH is the hormone clients with diabetes insipidus lack. The client's TSH, FSH, and LH levels won't be affected. 13. Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? a. Diabetic ketoacidosis b. Thyroid crisis c. Hypoglycemia d. Tetany - correct answer B. Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia. 14. For a male client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? a. Cool, clammy skin b. Distended neck veins c. Increased urine osmolarity d. Decreased serum sodium level - correct answer C. In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing fluid volume deficit. Cool, clammy skin; distended neck veins; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance. 15. When assessing a male client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, nurse April is most likely to detect: a. a blood pressure of 130/70 mm Hg. b. a blood glucose level of 130 mg/dl. c. bradycardia. d. a blood pressure of 176/88 mm Hg. - correct answer D. Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn't associated with the other options. 16. A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a. Infusing I.V. fluids rapidly as ordered b. Encouraging increased oral intake c. Restricting fluids d. Administering glucose-containing I.V. fluids as ordered - correct answer C. To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load. 17. A female client has a serum calcium level of 7.2 mg/dl. During the physical examination, nurse Noah expects to assess: a. Trousseau's sign. b. Homans' sign. c. Hegar's sign. d. Goodell's sign. - correct answer A. This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy. 18. Which outcome indicates that treatment of a male client with diabetes insipidus has been effective? a. Fluid intake is less than 2,500 ml/day. b. Urine output measures more than 200 ml/hour. c. Blood pressure is 90/50 mm Hg. d. The heart rate is 126 beats/minute. - correct answer A. Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued fluid deficit, suggesting that treatment hasn't been effective. 19. Jemma, who weighs 210 lb (95 kg) and has been diagnosed with hyperglycemia tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that she has large hands and a hoarse voice. Which of the following would the nurse suspect as a possible cause of the client's hyperglycemia? a. Acromegaly b. Type 1 diabetes mellitus c. Hypothyroidism d. Deficient growth hormone - correct answer A. Acromegaly, which is caused by a pituitary tumor that releases excessive growth hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this disorder. The accompanying soft tissue swelling causes hoarseness and often sleep apnea. Type 1 diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin. Hypothyroidism isn't associated with hyperglycemia, nor is growth hormone deficiency. 20. Nurse Kate is providing dietary instructions to a male client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: a. Increasing saturated fat intake and fasting in the afternoon. b. Increasing intake of vitamins B and D and taking iron supplements. c. Eating a candy bar if light-headedness occurs. d. Consuming a low-carbohydrate, high-protein diet and avoiding fasting. - correct answer D. To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia. 21. An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: a. Thyroid storm. b. Cretinism. c. myxedema coma. d. Hashimoto's thyroiditis. - correct answer C. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role. 22. A male client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. Nurse Jack explains that these medications are only effective if the client: a. prefers to take insulin orally. b. has type 2 diabetes. c. has type 1 diabetes. d. is pregnant and has type 2 diabetes. - correct answer B. Oral antidiabetic agents are only effective in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. Pregnant and lactating women aren't prescribed oral antidiabetic agents because the effect on the fetus is uncertain. 23. When caring for a female client with a history of hypoglycemia, nurse Ruby should avoid administering a drug that may potentiate hypoglycemia. Which drug fits this description? a. sulfisoxazole (Gantrisin) b. mexiletine (Mexitil) c. prednisone (Orasone) d. lithium carbonate (Lithobid) - correct answer A. Sulfisoxazole and other sulfonamides are chemically related to oral antidiabetic agents and may precipitate hypoglycemia. Mexiletine, an antiarrhythmic, is used to treat refractory ventricular arrhythmias; it doesn't cause hypoglycemia. Prednisone, a corticosteroid, is associated with hyperglycemia. Lithium may cause transient hyperglycemia, not hypoglycemia. 24. After taking glipizide (Glucotrol) for 9 months, a male client experiences secondary failure. Which of the following would the nurse expect the physician to do? a. Initiate insulin therapy. b. Switch the client to a different oral antidiabetic agent. c. Prescribe an additional oral antidiabetic agent. d. Restrict carbohydrate intake to less than 30% of the total caloric intake. - correct answer B. Many clients (25% to 60%) with secondary failure respond to a different oral antidiabetic agent. Therefore, it wouldn't be appropriate to initiate insulin therapy at this time. However, if a new oral antidiabetic agent is unsuccessful in keeping glucose levels at an acceptable level, insulin may be used in addition to the antidiabetic agent. 25. During preoperative teaching for a female client who will undergo subtotal thyroidectomy, the nurse should include which statement? a. "The head of your bed must remain flat for 24 hours after surgery." b. "You should avoid deep breathing and coughing after surgery." c. "You won't be able to swallow for the first day or two." d. "You must avoid hyperextending your neck after surgery." - correct answer D. To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing. What is a hormone secreted from the posterior lobe of the pituitary gland? Answers: A. LH B. MSH C. ADH D. GnRH - correct answer . C ADH is secreted from the posterior pituitary. LH comes from the anterior pituitary, MSH from the intermediate. GnRH is released from the hypothalamus. An indication of Chvostek' sign is: Answers: A. Twitching of the lips after tapping the face B. Elevated blood sugar after glucose infusion C. Inability to hold one's arms straight D. Spasms of the hand after blood circulation is cut off - correct answer . A Twitching of the lips after tapping the face in the right place is an indication of Chvostek's sign and a sign of hypocalcaemia. Spasms of the hand are associated with Trousseau's sign. A 26 year old female client presents with the symptom of unwanted facial hair. What of the following conditions is most likely? Answers: A. Graves' disease B. PCOS C. Hyperthyroidism D. Addison's disease - correct answer B PCOS is well known to cause hormonal irregularities in women which can result in hair growth. In explaining the condition to a client, a nurse would say that Cushing's syndrome is caused primarily by: Answers: A. Low levels of glucocorticoids B. Excess secretion of sodium C. Autoimmunity in the pancreas D. Elevated levels of cortisol - correct answer D Cushing's syndrome is caused by elevated levels of cortisol. Glucocorticoids tend to cause this. Which of the following symptoms is not typical of Cushing's syndrome? Answers: A. Osteoporosis B. Weight loss C. Diabetes D. Mood instability - correct answer B Cushing's syndrome tends to produce rapid weight gain, not weight loss. Which of the following would be an indication of Androgen Insensitivity Syndrome? Answers: A. A 33 year old woman with a karyotype of XY B. A 16 year old male with reduced kidney function C. Failure to respond to cortisol therapy D. Several pregnancies all of which ended in miscarriages - correct answer A Androgen Insensitivity Syndrome is when the body does not respond to androgens such as testosterone. This can result in genetic males being born with the appearance of women. A client presents with hypocalcemia, hyperphosphatemia, muscle cramps, and positive Trosseau's sign. What diagnosis does this support? Answers: A. Diabetes insipidus B. Conn's syndrome C. Hypoparathyroidism D. Acromegaly - correct answer C Hypoparathyroidism often leads to the symptoms mentioned. Conn's syndrome is an aldosterone-producing adenoma. A client with Graves' disease experiences a thyroid storm and has tachycardia and hypertension. What medication is most likely to be used? Answers: A. Levofloxcin B. Chlorothiazide C. Percocet D. Propylthiouracil - correct answer . D Propylthiouracil is a commonly used medication for treating hyperthyroidism. Levofloxacin is an antibiotic, chlorothiazide is a diuretic, and Percocet a painkiller. Which of the following statements by a client with Type II Diabetes indicates the need for further education? Answers: A. I should avoid hot tubs B. I should aim for an HbA1C level of 5.5% C. I may need insulin at times D. My life expectancy is likely reduced by 10 years - correct answer . B While an HbA1C level of 5.5% would be below the threshold for diabetes, it is an unrealistic target. Data has shown that trying to lower the HbA1C level too much can lead to an increase in complications. In educating a client, the nurse is likely to explain the following is the cause of Hashimoto's disease: Answers: A. Antibodies attacking the thyroid gland B. Inflammation in the kidneys C. An adenocarcinoma in the brain D. Overactivation of the pituitary gland - correct answer A Hashimoto's disease is caused by autoimmunity to the thyroid gland, often involving antibodies. Acromegaly is most frequently diagnosed in: a. Middle-aged adults b. Newborns c. Children ages 2 to 5 d. Adults age 65 and older - correct answer . A: Acromegaly results from benign tumors on the pituitary gland that produce excessive amounts of growth hormone. Although symptoms may present at any age, the diagnosis generally occurs in middle-aged persons. Untreated, the consequences of acromegaly include 2. Grave's disease is: a. The most common cause of hypothyroidism b. The most common cause of hyperparathyroidism c. The most common cause of hyperthyroidism d. The most common cause of adrenal insufficiency - correct answer type 2 diabetes, hypertension and increased risk of cardiovascular disease, arthritis and colon polyps. 2. C: Grave's disease is an autoimmune disorder characterized by an enlarged thyroid gland and overproduction of thyroid hormones producing symptoms of hyperthyroidism such as rapid heartbeat, heat intolerance, agitation or irritability, weight loss, and trouble sleeping. It usually presents in persons age 20 to 40 and it is much more common in women than in men. 3. Symptoms of Grave's ophthalmopathy include all of the following except: a. Bulging eyeballs b. Dry, irritated eyes and puffy eyelids c. Cataracts d. Light sensitivity - correct answer 3. C: Grave's ophthalmopathy is an inflammation of tissue behind the eye causing the eyeballs to bulge. In addition to the above-mentioned symptoms, Grave's ophthalmopathy may cause pressure or pain in the eyes, double vision, and trouble moving the eyes. About one-quarter of persons with Grave's disease develop Grave's ophthalmopathy. The condition is frequently self-limiting, resolving without treatment over the course of a year or two. 4. An ACTH stimulation test is commonly used to diagnose: a. Grave's disease b. Adrenal insufficiency and Addison's disease c. Cystic fibrosis d. Hashimoto's disease - correct answer 4. B: The ACTH stimulation test measures blood and urine cortisol before and after injection of ACTH. Persons with chronic adrenal insufficiency or Addison's disease generally do not respond with the expected increase in cortisol levels. An abnormal ACTH stimulation test may be followed with a CRH stimulation test to pinpoint the cause of adrenal insufficiency. 5. All of the following are symptoms of Cushing's syndrome except: a. Severe fatigue and weakness b. Hypertension and elevated blood glucose c. A protruding hump between the shoulders d. Hair loss - correct answer 5. D: Cushing's syndrome also may cause fragile, thin skin prone to bruises and stretch marks on the abdomen and thighs as well as excessive thirst and urination and mood changes such as depression and anxiety. Women who suffer from high levels of cortisol often have irregular menstrual cycles or amenorrhea and present with hair on their faces, necks, chests, abdomens, and thighs. 6. Which of the following conditions is caused by long-term exposure to high levels of cortisol? a. Addison's disease b. Crohn's disease c. Adrenal insufficiency d. Cushing's syndrome - correct answer 6. D: Cushing's syndrome is a form of hypercortisolism. Risk factors for Cushing's syndrome are obesity, diabetes, and hypertension. Cushing's syndrome is most frequently diagnosed in persons ages 20 to 50 who have characteristic round faces, upper body obesity, large necks, and relatively thin limbs. 7. A "sweat test" or newborn screening may be used to detect: a. Cystic fibrosis b. Adrenal insufficiency c. Grave's disease d. Hypothyroidism - correct answer 7. A: Cystic fibrosis is the most common inherited fatal disease of children and young adults in the United States. Cystic fibrosis is usually diagnosed by the time an affected child is three years old. Often, the only signs are a persistent cough, a large appetite but poor weight gain, an extremely salty taste to the skin, and large, foul-smelling bowel movements. A simple sweat test is currently the standard diagnostic test. The test measures the amount of salt in the sweat; abnormally high levels are the hallmark of the disorder. 8. Hashimoto's disease is: a. Chronic inflammation of the thyroid gland b. Diagnosed most frequently in Asian-Americans and Pacific Islanders c. A form of hyperthyroidism d. A rare form of hypothyroidism - correct answer 8. A: Hashimoto's disease is the most common cause of hypothyroidism. It is an autoimmune disease that produces chronic inflammation of the thyroid gland. More women are affected than men and it is generally diagnosed in persons ages 40 to 60. When treatment is indicated, synthetic T4 is administered. 9. Persons at increased risk of developing Hashimoto's disease include all of the following except: a. Persons with vitiligo b. Asian-Americans c. Persons with rheumatoid arthritis d. Persons with Addison's disease - correct answer 9. B: Along with the above-mentioned groups, persons with type 1 diabetes and persons suffering from pernicious anemia (insufficient vitamin b12) are at increased risk of developing Hashimoto's disease. Because it tends to run in families, there is likely a genetic susceptibility as well. Environmental factors such as excessive iodine consumption and selected drugs also have been implicated as potential risk factors. 10. All of the following statements about Hashimoto's disease are true except: a. Many patients are entirely asymptomatic b. Not all patients become hypothyroid c. Most cases of obesity are attributable to Hashimoto's disease d. Hypothyroidism may be subclinical - correct answer 10. C: Although weight gain may be a symptom of Hashimoto's disease, the majority of obese people have normal thyroid function; rarely is thyroid disorder the sole cause of obesity. Other symptoms of Hashimoto's disease include fatigue, cold intolerance, joint pain, myalgias, constipation, dry hair, skin and nails, impaired fertility, slow heart rate, and depression. 11. The most common benign tumor of the pituitary gland is a: a. Glioma b Prolactinoma c. Carcinoid tumor d. Islet cell tumor - correct answer 11. B: Prolactinomas can cause symptoms by releasing excessive amounts of prolactin into the blood or mechanically by pressing on surrounding tissues. In women, symptoms may include menstrual irregularities and infertility; in men erectile dysfunction and libido may be impaired. 12. Symptoms of polycystic ovarian syndrome (PCOS) may include all of the following except: a. Pelvic pain b. Acne, oily skin, and dandruff c. Infertility d. Weight Loss - correct answer 12. D: In addition to the above-mentioned symptoms, PCOS may cause menstrual irregularities, thinning hair or male-pattern baldness, thick skin or dark patches of skin and excessive hair growth on the face, chest, abdomen, thumbs and toes. 13. Women with PCOS are at increased risk for all of the following except: a. Pregnancy b. Diabetes c. Cardiovascular disease d. Metabolic syndrome - correct answer 13. A: Women with PCOS produce excessive amounts of androgens and do not release ova during ovulation, which seriously compromises their ability to conceive. Although women with PCOS can become pregnant, often by using assistive reproductive technology, they are at increased risk for miscarriage. 14. All of the following organs may be affected by multiple endocrine neoplasia type 1 except: a. Parathyroid glands b. Kidneys c. Pancreas and Duodenum d. Pituitary gland - correct answer 14. B: Multiple endocrine neoplasia type 1, also known as Werner's syndrome, is a heritable disorder that causes tumors in endocrine glands and the duodenum. Although the tumors associated with multiple endocrine neoplasia type 1 are generally benign, they can produce symptoms chemically by releasing excessive amounts of hormones or mechanically by pressing on adjacent tissue. 15. What is the treatment for hyperparathyroidism? a. Synthetic thyroid hormone b. Desiccated thyroid hormone c. Surgical removal of the glands d. Calcium and phosphate - correct answer 15. C: When hyperparathyroidism requires treatment, surgery is the treatment of choice and is considered curative for 95% of cases. Because untreated hyperparathyroidism may elevate blood and urine levels of calcium and deplete phosphorus, bones and teeth may lose the minerals needed to remain strong. 16. The most common causes of death in people with cystic fibrosis is: a. Dehydration b. Opportunistic infection c. Lung cancer d. Respiratory failure - correct answer 16. D: Declining pulmonary function is a hallmark of cystic fibrosis. Drugs such as Pulmozyme (dornase alfa) and Zithromax (azithromycin) can slow the progression of lung disease and mechanical physical therapy devices help CF patients to breathe more easily by loosening and dislodging mucus. For some patients with severe lung damage, lung transplantation is a treatment option. 17. Untreated hyperthyroidism during pregnancy may result in all of the following except: a. Premature birth and miscarriage b. Low birthweight c. Autism d. Preeclampsia - correct answer 17. C: In addition to the above-mentioned complications of uncontrolled hyperthyroidism in pregnancy, expectant mothers may suffer congestive heart failure and thyroid storm, which is life-threatening thyrotoxicosis with symptoms that include agitation, confusion, tachycardia, shaking, sweating, diarrhea, fever, and restlessness. 18. Short stature and undeveloped ovaries suggest which of the following disorders: a. Polycystic ovarian syndrome b. Prolactinoma c. Grave's disease d. Turner syndrome - correct answer 18. D: Turner syndrome results from a chromosomal abnormality and occurs in an estimated 1 in 2,500 female births. It occurs more frequently in preterm pregnancies. Affected women are shorter than average and are infertile because they lack ovarian function. They also may have webbed necks, broad chests, arms that turn out from the elbow, lymphedema of the hands and feet and skeletal, cardiac, and renal problems. 19. Endocrine disorders may be triggered by all of the following except: a. Stress b. Infection c. Chemicals in the food chain and environment d. Cell phone use - correct answer 19. D: Endocrine function may be influenced by myriad factors. In addition to the above-mentioned, there is evidence that exposure to naturally occurring and man-made endocrine disruptors such as tributyltin, certain bioaccumulating [Show Less]
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2023 NCLEX RN EXAM TEST BANK 900 ACTUAL EXAM Q&A 100% VERIFIED
1. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C... [Show More] ) 40 year-old Caucasian nurse D) 55 year-old Hispanic teacher The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising. 2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids. 3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. 4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client‟s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client‟s pain. 5. What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height. 6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is „usually much lower.‟ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long. 7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens- Johnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home. 8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia 9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status The correct answer is D: Notify the health care provider of the child''s status These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction. 10. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents 11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. 12. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future. 13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day The correct answer is C: Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. 14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container. 15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse‟s response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation. 16. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli D) Emotional lability The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA. 17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough D) Meconium ileus The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF. 18. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient D) Instruct the client's wife to call the doctor if his symptoms become worse The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest. 19. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination. 20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk." The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers. 21. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling. 22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls." B) "I will set limits on exploring the house." C) "I understand the need to use those new skills." D) "I intend to keep control over our child." The correct answer is C: "I understand the need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment. 23. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube B) Check that the feeding solution matches the dietary order C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) Ensure that feeding solution is at room temperature The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration. 24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication. 25. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) All striated muscles B) The cerebellum C) The kidneys D) The leg bones The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle. 26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to A) Achieve harmony B) Maintain a balance of energy C) Respect life D) Restore yin and yang The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. 27. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein B) Restrict fluids C) Force fluids and reassess blood pressure D) Limit fluids to non-caffeine beverages The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. 28. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right-sided heart function is assessed through the evaluation of the central venous pressures (CVP). 29. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airway D) Obtain the crash cart The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest. 30. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 C) Urine output 50 ml/hour D) Respiratory rate 16 The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60- 100; systolic B/P over 100) in order to safely administer both medications. 31. While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying [Show Less]
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