01. Answer: C
Rational: A post-operative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. An anesthesia reaction would not occur on the second post-operative day. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.
02. Answer: B
Rational: Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat.
03. Answer: b
Rational: Hypoglycemia in diabetes mellitus causes confusion, indicating the need for carbohydrates. Polydipsia, blurred vision, and polyphagia are symptoms of hyperglycemia.
04.Answer a
Rational: If the nurse administers the client's normal daily dose of insulin while he's on nothing-by-mouth status before surgery, he'll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren't effective for type 1 diabetes. I.V. insulin infusions aren't necessary to manage blood glucose levels in clients undergoing routine surgery.
05.Answer a
Rational: The client's response indicates that he's in denial and needs further insight and education about his condition. Letting the client know that the nurse has his best interests in mind helps him accept the wound-care nurse. Although telling the client that his condition is serious and that the wound care nurse will see him that day are true statements, they're much too direct and may increase client resistance. Telling the client he could lose his foot is inappropriate and isn't therapeutic communication.
06.Answer d
Rational: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.
07.Answer: a
Rational: The patient who is having Kussmaul respirations would have abnormally deep, regular and increased respirations. Bradypnea would produce regular, slow respirations. Hyperpnea is labored, increased respirations, and apnea is when a patient stops breathing for short periods of time.
08.Answer a
Rationale: Pheochromocytomas are tumors of chromaffin tissues in the adrenal medulla. These tumors which are usually benign produce catecholamines (epinephrine or norepinephrine) that stimulate the sympathetic nervous system. Although many organs are affected, the most dangerous effects are peripheral vasoconstriction and increased cardiac rate and contractility with resultant paroxysmal hypertension. Systolic blood pressure may rise to 200 to 300 mmHg, the diastolic to 150 to 175 mmHg. # 1 is correct because the careful monitoring of blood pressure is essential. Attacks are often precipitated by physical, emotional, or environmental stimuli, so # 2 is incorrect because more than physical stressors are considered. This condition is life threatening and is usually treated with surgery as the preferred treatment. # 3 is incorrect because it is a random sample and not a 24 hour urine collection. Because catecholamine secretion is episodic, a 24-hour urine is a better surveillance method than serum catecholamines. (Pagana & Pagana, 2002). Surgical removal of the tumor(s) by adrenalectomy is the treatment of choice. # 4 is incorrect because surgery would be the treatment usually completed.
09.Answer d
Rationale: All of the above assessments have importance, but airway and breathing in a client should always be addressed first when prioritizing care. Assess for signs of latent tetany due to calcium deficiency, including tingling of toes, fingers, and lips; muscular twitches; positive Chvostek’s and Trousseau’s signs; and decreased serum calcium levels. However, tetany may occur in 1 to 7 days after thyroidectomy so # 1 is not the highest priority. Assessing for hemorrhage is always important, but the danger of hemorrhage is greatest in the first 12 to 24 hours after surgery, and as this client is immediately post operative it is not the main concern at this time. Pain medication is important but according to Maslow, pain is a psychosocial need to be addressed after a physiologic need.
10.Answer d
Rationale: The client with hyperthyroidism typically has an increased appetite, yet loses weight and may have hypermotile bowels and diarrhea. Additional manifestations related to hypermetabolism include heat intolerance, insomnia, palpitations, and increased sweating. # 1 is incorrect because pretibial myxedema is a rare characteristic of Graves’ disease. It is manifested by plaques and nodule development bilaterally over the shins and dorsal surface of the feet. # 3 is incorrect because proptosis is the forward displacement of the eye. # 4 is incorrect because the symptoms in the stem describe symptoms of hyperthyroidism, and not hypothyroidism. In hypothyroidism, clients characteristically have the manifestations of goiter, fluid retention and edema, decreased appetite, weight gain, constipation, dry skin, dyspnea, pallor, hoarseness, and muscle stiffness.
11. Answer d
Rational: An insufficient level of thyroid hormone causes a decrease in metabolic rate and heat production. Intolerance to cold would be noted. Options A, B and C are clinical manifestations of hyperthyroidism.
12.Answer c.
Rational: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or traumatized during surgery. If the client develops numbness and tingling around the mouth or in the fingertips or toes, muscle spasms, or twitching, the physician should be called immediately. A hoarse or weak voice may occur temporarily if there has been unilateral injury to the laryngeal nerve during surgery. Pain is expected in the postoperative period. Calcium gluconate ampules should be available at the bedside, and the client should have a patent intravenous (IV) line in the event that hypocalcemic tetany occurs.
13. Answer a
Rational: Thyroid storm is a potentially fatal acute episode of thyroid overactivity characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. Because it is an emergency, thyroid storm requires heroic interventions for control. The high fever is treated with hypothermic blankets, and dehydration is reversed with intravenous fluids. Options C and D are treatment measures for hypothyroidism.
Proudly powered by
0 comments:
Post a Comment