1. A 45-year-old male patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse
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a. Have you had a recent head injury?
b. Do you have to wear larger shoes now?
c. Is there a family history of acromegaly?
d. Are you experiencing tremors or anxiety?
ANS: B
Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.
DIF: Cognitive Level: Apply (application) REF: 1157
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A 42-year-old female patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma.
During preoperative teaching, the nurse instructs the patient about the need to
a. cough and deep breathe every 2 hours postoperatively.
b. remain on bed rest for the first 48 hours after the surgery.
c. avoid brushing teeth for at least 10 days after the surgery.
d. be positioned flat with sandbags at the head postoperatively.
ANS: C
To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.
DIF: Cognitive Level: Apply (application) REF: 1158
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included?
a. Palpate extremities for edema.
b. Measure urine volume every hour.
c. Check hematocrit every 2 hours for 8 hours.
d. Monitor continuous pulse oximetry for 24 hours.
ANS: B
After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.
DIF: Cognitive Level: Apply (application) REF: 1158
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. The nurse is assessing a 41-year-old African American male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include
a. high blood pressure.
b. decreased facial hair.
c. elevated blood glucose.
d. tachycardia and cardiac palpitations.
ANS: B
Changes in male secondary sex characteristics such as decreased facial hair, testicular atrophy, diminished spermatogenesis, loss of libido, impotence, and decreased muscle mass are associated with decreases in follicle stimulating hormone (FSH) and luteinizing hormone (LH). Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in adrenocorticotropic hormone (ACTH) and cortisol. Bradycardia is likely due to the decrease in thyroid stimulating hormone (TSH) and thyroid hormones associated with panhypopituitarism.
DIF: Cognitive Level: Apply (application) REF: 1159
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. Which information will the nurse include when teaching a 50-year-old male patient about somatropin (Genotropin)?
a. The medication will be needed for 3 to 6 months.
b. Inject the medication subcutaneously every day.
c. Blood glucose levels may decrease when taking the medication.
d. Stop taking the medication if swelling of the hands or feet occurs.
ANS: B
Somatropin is injected subcutaneously on a daily basis, preferably in the evening. The patient will need to continue on somatropin for life. If swelling or other common adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels.
DIF: Cognitive Level: Apply (application) REF: 1159
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
6. The nurse determines that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patients
a. weight has increased.
b. urinary output is increased.
c. peripheral edema is decreased.
d. urine specific gravity is increased.
ANS: B
Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.
DIF: Cognitive Level: Apply (application) REF: 1160
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
7. The nurse determines that additional instruction is needed for a 60-year-old patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient says which of the following?
a. I need to shop for foods low in sodium and avoid adding salt to food.
b. I should weigh myself daily and report any sudden weight loss or gain.
c. I need to limit my fluid intake to no more than 1 quart of liquids a day.
d. I will eat foods high in potassium because diuretics cause potassium loss.
ANS: A
Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other
patient statements are correct and indicate successful teaching has occurred. DIF: Cognitive Level: Apply (application) REF: 1161
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
8. A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n)
a. elevated hematocrit.
b. decreased serum sodium.
c. low urine specific gravity.
d. increased serum chloride.
ANS: B
When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.
DIF: Cognitive Level: Understand (comprehension) REF: 1160
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is
a. excess fluid volume related to intake greater than output.
b. impaired gas exchange related to fluid retention in lungs.
c. sleep pattern disturbance related to frequent waking to void.
d. risk for impaired skin integrity related to generalized edema.
ANS: C
Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.
DIF: Cognitive Level: Apply (application) REF: 1161
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
10. Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves disease?
a. Exercise is contraindicated to avoid increasing metabolic rate.
b. Restriction of iodine intake is needed to reduce thyroid activity.
c. Antithyroid medications may take several months for full effect.
d. Surgery will eventually be required to remove the thyroid gland.
ANS: C
Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves disease although surgery may be used.
DIF: Cognitive Level: Apply (application) REF: 1166
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
11. A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next?
a. Suction the patients airway.
b. Administer IV calcium gluconate.
c. Plan for emergency tracheostomy.
d. Prepare for endotracheal intubation.
ANS: B
The patients clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.
DIF: Cognitive Level: Apply (application) REF: 1168
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
12. Which nursing action will be included in the plan of care for a 55-year-old patient with Graves disease who has exophthalmos?
a. Place cold packs on the eyes to relieve pain and swelling.
b. Elevate the head of the patients bed to reduce periorbital fluid.
c. Apply alternating eye patches to protect the corneas from irritation.
d. Teach the patient to blink every few seconds to lubricate the corneas.
ANS: B
The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.
DIF: Cognitive Level: Apply (application) REF: 1167
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
13. A 62-year-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient
a. about radioactive precautions to take with all body secretions.
b. that symptoms of hyperthyroidism should be relieved in about a week.
c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect.
d. to discontinue the antithyroid medications taken before the radioactive therapy.
ANS: C
There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.
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