Chapter 46 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 46

Question 1

Type: MCSA

During the assessment of a patient with thyroid dysfunction, the nurse notes hair loss and warm, moist skin. Which question is most important for the nurse to ask this patient?

1. Have you experienced any recent weight loss?

2. Have you been feeling constipated?

3. Have you noticed increased bruising?

4. Have you noticed that you do not tolerate cold as well as you once did?

Correct Answer: 1

Rationale 1: Hair loss and warm, moist skin are both findings associated with hyperthyroidism. Weight loss is another finding that would support a diagnosis of hyperthyroidism.

Rationale 2: Constipation is a symptom of hypothyroidism. People with hypothyroidism have dry skin and cold extremities, so the patients findings do not support a diagnosis of hypothyroidism.

Rationale 3: Bruising and delayed wound healing support a diagnosis of hypothyroidism. People with hypothyroidism have dry skin and cold extremities, so the patients findings do not support a diagnosis of hypothyroidism.

Rationale 4: Cold intolerance is a finding associated with hypothyroidism. People with hypothyroidism have dry skin and cold extremities, so the patients findings do not support a diagnosis of hypothyroidism.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 2

Type: MCSA

Which instruction would be most important for the nurse to give to a patient who is scheduled to have a subtotal thyroidectomy?

1. Report sensations of tingling in toes, fingers, or lips.

2. Report headache immediately.

3. Herbal remedies are appropriate for use postoperatively.

4. Avoid exposure to crowds for several weeks after surgery.

Correct Answer: 1

Rationale 1: Hypoparathyroidism may result from the manipulation of the parathyroid glands during a subtotal thyroidectomy. The lack of circulating PTH causes hypocalcemia. Neuromuscular manifestations include numbness and tingling around the mouth and in the fingertips.

Rationale 2: Headache is not an emergent sign of any complication of this surgery.

Rationale 3: Herbal therapies should be used with extreme caution and only after consultation with the patients health care provider.

Rationale 4: There is no indication that the patient should avoid crowds any more than with any other surgical procedure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-3

Question 3

Type: MCSA

The nurse is caring for a patient with elevated serum T3 and T4 levels who receives a new prescription for methimazole (Tapazole). Which patient statement indicates understanding of instructions about this medication?

1. This medication will increase my metabolism.

2. As long as I take this medication daily, the time of the dose is not important.

3. This medication will cure my thyroid problem.

4. I will need regular blood tests while taking this medication.

Correct Answer: 4

Rationale 1: Hyperthyroidism is treated by administering methimazole or PTU, medications that reduce TH production, thereby decreasing metabolism.

Rationale 2: Consistency of dosing time is important with methimazole.

Rationale 3: Antithyroid medications are not cures, but rather serve to balance thyroid hormones.

Rationale 4: The patients white blood cell counts and liver function should be monitored while taking this medication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 46-3

Question 4

Type: MCSA

The nurse is caring for a patient with elevated serum thyroid hormones and new-onset exophthalmos. The nurse establishes which nursing diagnosis?

1. Disturbed Body Image

2. Risk for Infection

3. Imbalanced Nutrition: More than Body Requirements

4. Fluid Volume Excess

Correct Answer: 1

Rationale 1: The bulging of the eyes characteristic of exophthalmos affects body image.

Rationale 2: The presence of exophthalmos may increase the risk of eye infection to some degree, but this diagnosis is not as likely to be a priority as another.

Rationale 3: A diagnosis of imbalanced nutrition is not related to exophthalmos.

Rationale 4: A diagnosis of excess fluid is not related to exophthalmos.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 46-3

Question 5

Type: MCMA

The nurse is assessing a female patient who has an abnormally high level of parathyroid hormone. Which assessment findings would be consistent with this diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Muscle weakness

2. Hypercalcemia

3. Diarrhea

4. Weight gain

5. Hypotension

Correct Answer: 1,2

Rationale 1: Muscle weakness is a neuromuscular effect of hyperparathyroidism.

Rationale 2: Increased resorption of calcium by the kidneys results in hypercalcemia.

Rationale 3: Constipation is a more common effect of hyperparathyroidism.

Rationale 4: Weight loss is a more common effect of hyperparathyroidism.

Rationale 5: Hypertension is a more common effect of hyperparathyroidism.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 6

Type: MCSA

A patient diagnosed with an adrenal gland alteration tells the nurse, I am rarely outside in the sun but Im getting such a tan! Which nursing intervention is a priority in addressing the patients concern?

1. Ask if the patient is still taking the prescribed steroid for Addisons disease.

2. Ask the patient what time of day he or she is outdoors.

3. Auscultate the patients lung sounds, particularly for wheezing.

4. Palpate the patients thyroid gland.

Correct Answer: 1

Rationale 1: One of the symptoms of adrenocortical hypofunction (Addisons disease) is hyperpigmentation. If the patient has stopped taking the prescribed steroid, symptomology may have developed.

Rationale 2: The patient has already reported spending limited time outdoors. Another question would be more relevant.

Rationale 3: Auscultation of lung sounds would not help in determining the cause of this skin change.

Rationale 4: Palpation of the thyroid gland would not help in determining the cause of this skin change.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 7

Type: MCSA

A patient comes into the emergency department with symptoms of an Addisonian crisis. What should the nurse be prepared to administer to assist this patient?

1. Intravenous fluids

2. Warm blankets

3. Thyroid replacement hormone

4. Blood transfusion

Correct Answer: 1

Rationale 1: The patient with Addisonian crisis (hyposecretion of adrenal hormones) may have a high fever, weakness, abdominal pain, severe hypotension, circulatory collapse, shock, and coma. Treatment consists of rapid intravenous replacement of fluids and glucocorticoids.

Rationale 2: The patient experiencing an Addisonian crisis may have a high fever, so warm blankets would not promote comfort or a therapeutic effect.

Rationale 3: There is no thyroid hormone insufficiency.

Rationale 4: There are no indications the patient is in need of a blood transfusion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 46-2

Question 8

Type: MCMA

The patient is being treated for hypothyroidism. Under which circumstances would the nurse monitor this patient for development of myxedema crisis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is injured in an automobile accident.

2. The patient develops a urinary tract infection.

3. The patient accidentally doubled the dose of thyroid replacement medications today.

4. The patient must have surgery for a ruptured appendix.

5. The patients husband just filed for divorce.

Correct Answer: 1,2,4,5

Rationale 1: Myxedema crisis may be precipitated by trauma.

Rationale 2: Myxedema crisis may be precipitated by infection.

Rationale 3: Excessive use of thyroid replacement medications would not precipitate myxedema crisis.

Rationale 4: Pain, infection, and worry about impending surgery can precipitate myxedema crisis.

Rationale 5: Stress can induce myxedema crisis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-1

Question 9

Type: MCSA

The nurse is reviewing the laboratory findings for a group of patients. The nurse knows that which set of diagnostic results is consistent with a diagnosis of primary hypothyroidism?

1. Elevated TSH, depressed T3 and T4

2. Elevated TSH, elevated T3 and T4

3. Depressed TSH, elevated T3 and T4

4. Depressed TSH, depressed T3 and T4

Correct Answer: 1

Rationale 1: Laboratory analysis will indicate an elevated TSH, as the pituitary attempts to stimulate the thyroid gland to produce thyroid hormone. Because of the disorder, the thyroid hormone levels T3 and T4 will be low.

Rationale 2: T3 and T4 are not elevated in hypothyroidism.

Rationale 3: T3 and T4 are not elevated in hypothyroidism.

Rationale 4: TSH is elevated in hypothyroidism as the pituitary gland attempts to stimulate the thyroid gland to produce thyroid hormone.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-1

Question 10

Type: MCMA

The nurse is developing a plan of care for a home care patient who has hyperparathyroidism and a serum calcium level of 12.0 mg/dL. Which measures should be included in the plan?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Promote patient ambulation and mobility.

2. Remind the patient to avoid activities that increase the risk for falls or injuries.

3. Teach the patient to increase daily oral intake of fluids.

4. Advise the patient to contact the health care provider if continual thirst is noted.

5. Encourage the use of calcium-based antacids for indigestion.

Correct Answer: 1,2,3,4

Rationale 1: Maintaining mobility will assist in recalcification.

Rationale 2: Patients with hyperparathyroidism are at risk for fracture.

Rationale 3: A diet with adequate fiber and fluid will promote normal bowel function.

Rationale 4: Being constantly thirsty is a sign of calcium imbalance and should be reported.

Rationale 5: Patients with mild hypercalcemia are urged to avoid antacids containing calcium.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-3

Question 11

Type: MCSA

A nurse notes that a patient who has hypoparathyroidism has a serum calcium level of 4.2 mg/dL. This finding would help reinforce which nursing diagnosis?

1. Risk for Injury

2. Chronic Confusion

3. Risk for Altered Tissue Perfusion: Renal

4. Impaired Gas Exchange

Correct Answer: 1

Rationale 1: The patient with hypocalcemia is at risk for injury from possible laryngospasm, cardiac dysrhythmias, or convulsions. The nurse must frequently monitor airway and respiratory status, cardiovascular status, and neurological status.

Rationale 2: Chronic Confusion is not associated with hypoparathyroidism.

Rationale 3: Altered Tissue Perfusion: Renal would be a greater risk in the patient with high calcium levels.

Rationale 4: Impairment of gas exchange is not associated with hypoparathyroidism.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 46-3

Question 12

Type: MCSA

A patient with chronic hyperfunction of the adrenal cortex is being assessed. The nurse would attribute which finding to the patients chronic condition?

1. General feeling of malaise

2. Recent weight loss

3. Hypotension

4. Yellowing of the cornea

Correct Answer: 1

Rationale 1: Patients with Cushing syndrome are at risk for depression, severe fatigue, and muscle weakness. These findings can contribute to a general feeling of illness and malaise.

Rationale 2: Patients with Cushing syndrome typically experience weight gain, not weight loss.

Rationale 3: Patients with Cushing syndrome generally experience hypertension.

Rationale 4: Yellowing of the cornea is not expected in Cushing syndrome and may indicate a different pathology.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 13

Type: MCSA

Which clinic patient would the nurse monitor for development of Cushing syndrome?

1. A patient who received radioactive iodine treatment for hyperthyroidism

2. A patient receiving steroid treatment for rheumatoid arthritis

3. A patient who has had surgery on the neck

4. A patient receiving radiation for a brain tumor

Correct Answer: 1

Rationale 1: The patient who received radioactive iodine treatment for hyperthyroidism is not at increased risk for Cushing syndrome.

Rationale 2: Patients receiving treatment for rheumatoid arthritis are frequently prescribed corticosteroids, which are a primary risk factor for Cushing syndrome.

Rationale 3: Neck surgery is not a risk factor for development of Cushing syndrome.

Rationale 4: Radiation and the presence of a brain tumor are not risk factors for Cushing syndrome.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-1

Question 14

Type: MCMA

A patient is scheduled to start taking prednisone (Dexasone). The nurse would monitor this patient for which side effects?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fat deposits in the abdominal and clavicle regions

2. Muscle weakness and wasting in the extremities

3. Delayed wound healing

4. Varicose leg veins

5. Hypotension

Correct Answer: 1,2,3

Rationale 1: Symptoms of Cushing syndrome include obesity and a redistribution of body fat to the abdominal region (central obesity), fat pads under the clavicle, a buffalo hump over the upper back, and a round moon face.

Rationale 2: Changes in protein metabolism cause muscle weakness and wasting, especially in the extremities.

Rationale 3: Poor wound healing is common.

Rationale 4: Integumentary effects include the development of abdominal striae, not varicose leg veins.

Rationale 5: Hypertension, rather than hypotension, is a common side effect.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 15

Type: MCSA

The nurse assesses a patient who has a diagnosis of Cushing syndrome. Which set of findings should the nurse follow up immediately?

1. Serum potassium 2.5 and blood pressure 150/90

2. Serum sodium 145 mEq/L and reports of muscle weakness

3. Serum calcium 11 mg/dL and reports of feelings of depression

4. Serum phosphorus 3 mg/dL and hirsutism

Correct Answer: 1

Rationale 1: Hypokalemia and hypertension occur with Cushing syndrome as potassium is lost and sodium is retained. Patients with hypokalemia are at risk for life-threatening dysrhythmias, and the primary health care provider should be contacted with these findings.

Rationale 2: The serum sodium value is within normal limits; the report of muscle weakness is noteworthy but is not a priority finding to report to the health care provider.

Rationale 3: The serum calcium value is within normal limits; the report of depression is noteworthy but is not a priority finding to report to the health care provider.

Rationale 4: The serum phosphorus value is within normal limits; the report of hirsutism is noteworthy but is not a priority finding to report to the health care provider.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-2

Question 16

Type: MCSA

The nurse is caring for a patient with Cushing syndrome who is scheduled for a surgical procedure to remove an adrenal cortex tumor. The nurse knows patient teaching regarding the procedure has been effective when the patient makes which statement?

1. The adrenal gland with the tumor will be removed.

2. I will need to take adrenal hormones for the rest of my life.

3. The tumor will be removed by the transsphenoidal route.

4. I will receive IV cortisol in preparation for the surgery.

Correct Answer: 1

Rationale 1: When Cushing syndrome is caused by an adrenal cortex tumor, an adrenalectomy may be performed to remove the tumor.

Rationale 2: Only one adrenal gland is usually involved. As another adrenal gland remains, patients do not need lifetime adrenal hormone replacement.

Rationale 3: Pituitary, not adrenal, tumors are removed transsphenoidally.

Rationale 4: The patient with Cushing syndrome is already experiencing elevated cortisol levels; IV cortisol is not indicated prior to adrenalectomy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 46-2

Question 17

Type: MCMA

The nurse working in the emergency department is caring for a patient with Addisons disease who has an oral temperature of 102F and blood pressure of 70/35. The patient is reporting weakness and abdominal pain. The nurse recognizes that which patient statements are likely related to the current manifestations?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I injured my leg last week when I fell off a ladder.

2. I think I have had the flu for the last week.

3. I have been using a tanning bed.

4. I take my prednisone (Deltasone) every day.

5. I have been increasing my intake of calcium-rich foods.

Correct Answer: 1,2

Rationale 1: Addisonian crisis is a life-threatening response to acute adrenal insufficiency. Trauma can be a trigger for this response.

Rationale 2: Addisonian crisis is a life-threatening response to acute adrenal insufficiency. A trigger is acute infection such as influenza.

Rationale 3: The use of tanning beds is not associated with Addisonian crisis.

Rationale 4: Patients are prescribed prednisone or related glucocorticoids to treat Addisons disease; they are not a cause of Addisonian crisis.

Rationale 5: Intake of calcium-rich foods is not associated with Addisonian crisis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 18

Type: MCSA

The nurse is caring for a patient who experienced a closed head injury 6 days ago. The patients urine output over the previous 24 hours was 10,000 mL. Total intake for the same period was 1,200 mL. Diabetes insipidus (DI) has been diagnosed. Which order would the nurse question?

1. Desmopressin (Minirin) 0.2 mg IM daily

2. Increased oral fluid intake

3. Serum electrolyte levels every 12 hours

4. Computed tomography scan of head

Correct Answer: 1

Rationale 1: Desmopressin is not given IM.

Rationale 2: Replacing lost fluids is an essential part of managing DI.

Rationale 3: It is important to monitor serum electrolyte levels in patients with DI and to treat imbalances.

Rationale 4: A CT scan is an appropriate diagnostic tool, as a pituitary gland tumor can be a causative factor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-2

Question 19

Type: MCSA

A patient with a diagnosis of acromegaly related to a benign pituitary tumor is scheduled to have surgical removal of the tumor by the transsphenoidal route. Which statement by the patient would indicate that the nurses teaching regarding the procedure has been effective?

1. I will clean my teeth and gums with a soft foam sponge after the procedure.

2. I should choose a wig before my head is shaved.

3. There may be drainage from my ears for a day or two after surgery.

4. Surgical placement marks on my head will wash off with soap and water.

Correct Answer: 1

Rationale 1: Acromegaly is treated by surgical removal or irradiation of the pituitary tumor. A transsphenoidal or transfrontal surgical procedure is most commonly performed. The transsphenoidal route requires that the nurse and patient clean the upper teeth carefully for at least 2 weeks after the surgery to maintain an intact suture line.

Rationale 2: These procedures do not require shaving of the head.

Rationale 3: Although patients should be educated to monitor for drainage of clear fluid from the transsphenoidal site, drainage should not be observed from the ear following this procedure.

Rationale 4: These procedures do not require marking of the scalp.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 46-3

Question 20

Type: MCSA

The nurse notes that a patient has thin arms and legs, purple striae on the abdomen, upper body obesity, and a round, red face. The nurse would ask additional assessment questions based on a possible disorder of which structure?

1. Hypothalamus

2. Adrenal gland

3. Parathyroid gland

4. Thyroid gland

Correct Answer: 2

Rationale 1: Disorder of the hypothalamus is not the most likely cause of these symptoms.

Rationale 2: These assessment findings are typical of Cushing syndrome, a hypermetabolic disorder of the adrenal cortex.

Rationale 3: Dysfunction of the parathyroid gland would not result in these findings.

Rationale 4: Dysfunction of the thyroid gland would not result in these findings.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 21

Type: MCMA

The nurse would monitor for which findings in a patient diagnosed with hypoparathyroidism?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Low protein

2. Low calcium

3. High phosphorous

4. Low potassium

5. High magnesium

Correct Answer: 2,3

Rationale 1: Low protein levels are not associated with hypoparathyroidism.

Rationale 2: When the production of parathyroid hormone is inadequate, hypocalcemia results.

Rationale 3: When the production of parathyroid hormone is inadequate, results include high phosphorous levels.

Rationale 4: A low potassium level is not associated with hypoparathyroidism.

Rationale 5: A low magnesium level is not associated with hypoparathyroidism.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 22

Type: MCMA

A patient who is beginning drug treatment for hypothyroidism asks the nurse, How do I know if the drug is working? How should the nurse reply?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. You will begin losing weight.

2. You will probably start feeling like your old self pretty quickly once treatment begins.

3. You will have to check with your doctor to see if the drug is working.

4. You should gradually begin to have more energy.

5. You will probably notice your concentration improving.

Correct Answer: 4,5

Rationale 1: The patient may or may not lose weight while taking this medication.

Rationale 2: Patients may need to build up the medication gradually to the appropriate maintenance level. Immediate improvement of symptoms is not expected.

Rationale 3: The patient should see some clinical evidence of the drugs effectiveness. Lab values, ordered by the health care provider, may validate the patients impressions.

Rationale 4: It may take a few weeks for the full effects of the drug to be evident. Close monitoring will be necessary to determine the correct dosage.

Rationale 5: The patient will begin to see a reversal of symptoms such as inability to concentrate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-3

Question 23

Type: MCMA

A patient has been prescribed the synthetic hormone levothyroxine. What medication instructions should the nurse provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Take the medication with juice or milk for best absorption.

2. You may need a stool softener when taking this medication.

3. Do not switch brands of levothyroxine without first discussing the change with your health care provider.

4. Plan to take this medication every day for the rest of your life.

5. Take your medication at least 4 hours before taking antacids containing calcium.

Correct Answer: 3,4,5

Rationale 1: Taking levothyroxine with juice or milk will interfere with the absorption of the drug.

Rationale 2: The patient may require a stool softener because of the effects of hypothyroidism, not because of the effects of the thyroid supplement.

Rationale 3: Different brands of levothyroxine may be metabolized differently. The patient should consult the health care provider if a brand change is necessary.

Rationale 4: The patient with hypothyroidism will need lifelong thyroid replacement.

Rationale 5: Calcium interferes with the absorption of thyroid hormone.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-3

Question 24

Type: MCMA

The nurse would consider incorporating which nursing diagnoses into the plan of care for a patient with acute adrenal insufficiency?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Risk of Ineffective Therapeutic Regimen Management

2. Hyponatremia

3. Fluid Volume Excess

4. Risk for Injury

5. Imbalanced Nutrition: Less than Body Requirements

Correct Answer: 1,2,4,5

Rationale 1: The medication regimen for adrenal insufficiency can be complex and includes knowing how and when to alter the dosage relative to increased stress.

Rationale 2: A patient with adrenal insufficiency may have a sodium deficit.

Rationale 3: Acute adrenal insufficiency results in fluid volume deficit.

Rationale 4: The patient with acute adrenal insufficiency is at risk for injury even after the acute phase of the imbalance is corrected. The patient should wear medical alert jewelry so the condition will be recognized by first responders and medical personnel.

Rationale 5: Acute adrenal insufficiency may result in anorexia and weight loss.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 46-3

Question 25

Type: MCMA

A patient with hypoparathyroidism has a low serum calcium level. How would the nurse test for the clinical manifestation consistent with this laboratory result?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have the patient open and close both hands.

2. Place a blood pressure cuff on the patients arm.

3. Tap over the patients facial nerve.

4. Press lightly on the patients shoulders.

5. Ask the patient to count backwards.

Correct Answer: 2,3

Rationale 1: Opening and closing the hands will not elicit findings associated with hypocalcemia.

Rationale 2: Placing a tourniquet or BP cuff on the patients arm to assess for carpopedal spasm can also indicate hypocalcemia. This is referred to as Trousseaus sign.

Rationale 3: Tapping over the facial nerve will cause spasm and twitching of the mouth, indicating hypocalcemia; this is referred to as Chvosteks sign.

Rationale 4: Pressing on the patients shoulders will not elicit findings associated with hypocalcemia.

Rationale 5: Having the patient count backwards is not significant to hypocalcemia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 26

Type: MCMA

Following surgery for hypersecretion of growth hormone, a patient complains of a supraorbital headache. The nurse suspects a possible CSF leak and would take which actions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Test any nasal drainage for glucose.

2. Maintain bed rest.

3. Inform the patient that headaches are expected.

4. Keep the head of the bed (HOB) elevated 30 degrees.

5. Administer antibiotics as ordered.

Correct Answer: 1,2,4,5

Rationale 1: The presence of glucose in nasal drainage indicates leakage of CSF.

Rationale 2: Postoperative care of patients with a potential CSF leak should include bed rest.

Rationale 3: Headaches are not expected after surgery and are a sign of a CSF leak.

Rationale 4: Postoperative care of patients with a CSF leak should include continued elevation of the HOB.

Rationale 5: Postoperative care of patients with a CSF leak should include the administration of prophylactic antibiotics.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-2

Question 27

Type: MCMA

The nurse is planning to present a community education session on advances in the diagnosis and treatment of endocrine disorders. Which topics should be included in this presentation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. More sensitive technology for hormonal assays

2. Development of new synthetic hormones

3. Standardized methods to prevent endocrine disorders

4. New diagnostic imaging technologies

5. Improvements in surgical techniques

Correct Answer: 1,2,4,5

Rationale 1: Significant advances have been made in the diagnosis and treatment of endocrine disorders in recent years due to the development of more sensitive hormonal assays.

Rationale 2: Several new synthetic hormones have been developed.

Rationale 3: Therapy for endocrine disorders is limited to early diagnosis and improved treatment. Prevention is not yet possible.

Rationale 4: Diagnostic imaging technologies continue to advance.

Rationale 5: There have been significant advances in surgical techniques for endocrine disorders.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 46-5

Question 28

Type: MCSA

When measuring the blood pressure of a patient with hypoparathyroidism, the nurse notes spasms of the patients hand. How should the nurse document this finding?

1. Trousseaus sign

2. Chvosteks sign

3. Turners sign

4. Cullens sign

Correct Answer: 1

Rationale 1: Trousseaus sign is elicited by placing a blood pressure cuff on the patients arm; when the cuff is inflated, the patient experiences carpal spasms of the hand.

Rationale 2: Chvosteks sign is elicited by tapping on the face in front of the ear and observing for contractions of the facial muscle.

Rationale 3: Turners sign is observed on a patients abdomen and flank and is associated with intra- or retroperitoneal bleeding.

Rationale 4: Cullens signs is observed on a patients abdomen and flank and is associated with intra- or retroperitoneal bleeding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 29

Type: MCMA

A patient with Graves disease is brought to the emergency department by her husband. He says that the couple have both had the flu and that she has not been able to keep anything down for about 3 days. The patient has a temperature of 103F, heart rate is 124bpm, respiratory rate 20, and blood pressure 150/88 mmHg. She complains of severe nausea and is very agitated. Which actions should the nurse take?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have both the patient and the husband put on isolations masks.

2. Notify the physician that another patient with possible influenza has been admitted to the ED.

3. Place the patient on a cardiac monitor.

4. Start an intravenous access device according to emergency protocol.

5. Stay with the patient while another nurse notifies the physician of the patients condition.

Correct Answer: 3,4,5

Rationale 1: There is no indication that this patient should be further stressed by being asked to wear an isolation mask.

Rationale 2: The nurse should not assume this patients symptomology is related to influenza.

Rationale 3: This patient should be monitored for the development of atrial fibrillation or other cardiac dysrhythmia. Thyroid storm may be occurring, as the patient is stressed and has not been able to take thyroid medication for 3 days.

Rationale 4: This patient is likely to need venous access for fluids and medications. The nurse should follow emergency protocols to insert this device. Thyroid storm may be occurring as the patient is stressed and has not been able to take thyroid medication for 3 days.

Rationale 5: Thyroid storm may be occurring as the patient is stressed and has not been able to take thyroid medication for 3 days. This is an emergent condition and treatment should begin immediately.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-2

Question 30

Type: MCMA

The nurse notifies the health care provider that a patient is experiencing signs of myxedema. What assessment parameters has the nurse noted?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Facial swelling

2. Anuria

3. Macroglossia

4. Fever

5. Bradycardia

Correct Answer: 1,3,5

Rationale 1: Facial edema is a finding associated with myxedema.

Rationale 2: Lack of urine output is not a finding immediately attributable to myxedema.

Rationale 3: Thickening of the tongue is associated with myxedema.

Rationale 4: Hypothermia is a finding associated with myxedema.

Rationale 5: Significantly slowed pulse is associated with myxedema.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 46-2

Question 31

Type: MCSA

A 70-year-old patient is prescribed levothyroxine for treatment of hypothyroidism. The nurse would expect which age-related adjustment in dosage?

1. The dosage will be higher than for younger patients.

2. The dose will be divided into two or three doses each day.

3. The dose will be the same as for younger adults, but greater than that for children.

4. The initial dose will be significantly lower for the older adult.

Correct Answer: 4

Rationale 1: The dose is not higher for older patients.

Rationale 2: Levothyroxine is given in one daily dose.

Rationale 3: The dose will not be the same as that for younger adults.

Rationale 4: The initial dose given to older adults is significantly lower than that given to younger adults. The dose may be increased according to drug effects.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-4

Question 32

Type: MCMA

Which interventions would the nurse plan to address the nursing diagnosis Risk for Impaired Skin Integrity for a patient with hypothyroidism?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Wash daily with antibacterial soap.

2. Apply emollient skin lotion liberally at least twice daily.

3. Use astringent wipes to reduce itching.

4. Assess the need for an alternating air mattress daily.

5. Clean areas between skin folds with alcohol to prevent a yeast infection.

Correct Answer: 2,4

Rationale 1: Antibacterial soap is drying and should not be used.

Rationale 2: Liberal use of emollient skin lotion will help reduce drying.

Rationale 3: Astringents are drying and may increase itching.

Rationale 4: The patient may benefit from an alternating air mattress. The nurse should assess for this need on a regular basis.

Rationale 5: Alcohol should not be used on the skin of patients with hypothyroidism.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-2

Question 33

Type: MCSA

During a routine physical, a 30-year-old patient remarks, I had to buy all new shoes because my feet are growing again. How should the nurse reply?

1. Have you noticed any changes in your hands?

2. That is not too bad a problem to have.

3. We should measure your height.

4. Have you noticed your heart beating faster?

Correct Answer: 1

Rationale 1: Changes in shoe size, glove size, or ring size in an adult may indicate growth hormone disturbance.

Rationale 2: The nurse should not make light of this remark as it may indicate pathology.

Rationale 3: Growth hormone disturbance would not cause increased height in an adult.

Rationale 4: Increased heart rate is not associated with growth hormone disturbance.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 46-3

Question 34

Type: MCSA

A patient has been admitted for treatment of syndrome of inappropriate antiduretic hormone secretion (SIADH). The nurse expects continued diagnostic tests for which disorder?

1. Heart failure

2. Small cell carcinoma of the lung

3. Hypertension

4. Pleural effusion

Correct Answer: 2

Rationale 1: Heart failure is not causative of SIADH.

Rationale 2: Small cell carcinoma of the lung is a frequent cause of SIADH.

Rationale 3: Hypertension is not a causative factor in SIADH.

Rationale 4: Pleural effusion is not a causative factor in SIADH.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 46-1

Question 35

Type: MCSA

An older adult is diagnosed with apathetic thyrotoxicosis. Which nursing diagnosis would the nurse prioritize in this patients care plan?

1. Anxiety

2. Depression

3. Risk for Injury: Falls

4. Decreased Tissue Perfusion: Peripheral

5.

Correct Answer: 3

Rationale 1: Anxiety may be present, but it does not have the highest priority.

Rationale 2: The patient may have depression, but this is not the diagnosis of highest priority.

Rationale 3: The patient with apathetic thyrotoxicosis has profound myopathy, especially in the quadriceps, which increases the risk for falls.

Rationale 4: The patient may have age-related or disease-related changes in tissue integrity, but this is not the highest-priority diagnosis.

Rationale 5:

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 46-4

 

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