E
The nurse would note which findings on the physical assessment of a client with a diagnosis of Cushing's disease? Select all that apply.
1. Buffalo hump
2. Thinning hair
3. Acne
4. Hirsutism
5. Gynecomastia
6. Bulging eyes
Correct Answer(s): 1,2,3,4,5
Rationale:
Typical clinical findings of Cushing's disease include thinning hair, hirsutism in women, gynecomastia in men, moon face, buffalo hump, abdominal striae, weight gain, truncal obesity, thin limbs, acne, hypertension, and mood changes. This may be due to externally administered steroids or excessive production of steroids by the adrenal glands. Bulging eyes are associated with hyperthyroidism.
A client is receiving treatment for Cushing's syndrome. Which laboratory measurement would provide an indication that treatment is successful?
1. A decreased serum potassium level
2. An increased urinary calcium level
3. An increased serum sodium level
4. A decreased serum glucose level
Correct Answer: 4
Rationale:
Cushing's syndrome is characterized by hyperglycemia, hypokalemia, hypernatremia, and hypercalciuria. A drop-in serum potassium and an increase in urinary calcium levels would not indicate improvement; however, a drop in serum glucose would indicate improvement.
The nurse is caring for a client who is postoperative for a thyroidectomy. Which observation should the nurse be most concerned about?
1. The client's wrist spontaneously flexes when the BP cuff is tightened.
2. The client complains of soreness around the throat.
3. The client has a BP of 140/90 mm Hg, a pulse of 90 beats/min, and respiration of 18 breaths/min.
4. The client supports her neck with both hands when turning.
Correct Answer: 1
Rationale:
Spontaneous flexing of the wrist is an early indication of carpal spasms, which may be indicative of hypocalcemia or tetany (Trousseau sign). Soreness around the throat would be expected. BP is elevated and should be monitored, but this is not as critical as the hypocalcemia. Nurses should encourage the client to support the head and neck when turning or changing positions after a thyroidectomy.
A client is being treated for Addisonian crisis and 0.9% saline solution is being administered. What nursing observation would indicate this intervention may not be achieving the desired response?
1. Ankle edema
2. Serum potassium of 4.1 mEq/L (4.1 mmol/L)
3. Decreasing blood pressure (BP)
4. Heart rate of 78 beats/min
Correct answer: 3
Rationale:
The purpose of the infusion of large volumes of saline is to reverse/prevent hypotension. Edema would not be expected, because this is associated with Cushing's syndrome. Hyperkalemia is associated with Addison disease. Sodium polystyrene sulfonate may be administered to clients experiencing higher-than-normal ranges of potassium levels in which bradycardia and irregular pulse are clinical findings. Decreasing BP may be considered a late sign of cardiac decompensation with decreased atrial and ventricular output. Pedal edema would not be associated in clients experiencing hyperkalemia because it is related to sodium retention.
A client has been diagnosed with Addison disease. Which changes in appearance would the nurse expect to see?
1. Moon face, truncal obesity, and purple abdominal striations
2. Nervousness, breast engorgement, and hirsutism
3. Truncal obesity, gaunt facial appearance, and skin tears
4. Discoloration of the mucous membranes, copper-colored skin, and weight loss
Correct answer: 4
Rationale:
Addison disease is characterized by fatigue, weight loss, anorexia, skin hyperpigmentation (bronzing), hypotension, hyponatremia, hyperkalemia, nausea, vomiting, and diarrhea. The other symptoms are associated with Cushing's syndrome.
The nurse would understand that moist skin with fine hair, prominent eyes, lid retraction, and a staring expression are characteristics associated with which disease process?
1. Graves disease
2. Multiple sclerosis
3. Cushing's syndrome
4. Diabetes
Rationale:
Graves disease, or hyperthyroidism, is an autoimmune disorder affecting the thyroid gland that has the following symptoms: moist skin, fine hair, prominent eyes, tachycardia, hypertension, and a staring expression. Multiple sclerosis is an autoimmune disorder of the nervous system characterized by muscle weakness and visual field disturbances (diplopia). Cushing's syndrome is caused by hypersecretion of corticosteroids by the adrenal glands and is characterized by thinning hair, hirsutism in women, gynecomastia in men, moon face, buffalo hump, abdominal striae, weight gain, truncal obesity, thin limbs, acne, hypertension, and mood changes. Diabetes is characterized by polyuria, polyphagia, and polydipsia.
The nurse is providing education to a client diagnosed with Addison disease. Which statement by the client would indicate that more education is needed?
1.
"I will make sure I carry my medical identification card wherever I go."
2.
"I am just glad I do not have to take steroids for the rest of my life."
3.
"If I have any stomach problems, I'll let the doctor know."
4.
"If I get an infection or injured, the doctor might have to give me more steroids."
Correct Answer: 2
Rationale:
Addison disease is caused by a decrease in secretion of adrenal cortex hormones. For a client diagnosed with Addison disease, lifelong steroid therapy is necessary. The client should carry a medical identification card that identifies his or her condition in case of an emergency. Gastric distress should be reported because it may be an indication of ulcer formation caused by steroids. An increase in steroid medication may be needed for an infection or injury.
After administering diuretics to a client with ascites, which nursing action most ensures safe care?
1. Monitoring serum potassium for hyperkalemia
2. Assessing the client for hypervolemia
3. Weighing client weekly
4. Documenting accurate intake and output
Correct Answer: 4
Rationale:
Accurate intake and output measurements are essential for clients receiving diuretics. Hypokalemia, not hyperkalemia, is a frequent occurrence with diuretic therapy. Hypovolemia is a greater risk with increased urine output. Clients should be weighed daily.
An obese 44-year-old woman with a history of chronic cholecystitis is to receive vitamin K before surgery. What is the purpose of this medication?
1. To increase the digestion and utilization of fats
2. To support the immune system and promote healing
3.To aid in the emptying of bile from the gallbladder
4. To facilitate coagulation activities of the blood
Correct Answer: 4
Rationale:
Vitamin K is necessary for normal clotting. Cholecystitis can decrease the absorption of fat-soluble vitamins (A, D, E, and K) by interfering with fat metabolism, which can lead to potential difficulties with clotting.
What statement would indicate to the nurse that the client understands the discharge teaching regarding his cirrhosis?
1.
"I will decrease vitamin B intake."
2.
"I need to continue taking acetaminophen daily."
3.
"I will weigh myself every day in the morning."
4.
"I can eat my regular diet."
Correct answer: 3
Rationale:
Daily weight measurement is essential to monitor for volume overload. Clients with cirrhosis need increased vitamin B, especially B6 (pyridoxine). Acetaminophen is hepatotoxic. The diet should be high in carbohydrates, include adequate amounts of protein to build tissue, and be moderate to low in fat intake.
While talking with a client with a diagnosis of end-stage liver disease, the nurse notices the client is unable to stay awake and seems to fall asleep in the middle of a sentence. The nurse recognizes these symptoms to be indicative of what condition?
1. Hyperglycemia
2. Increased bile production
3. Increased blood ammonia levels
4. Hypocalcemia
Correct Answer: 3
Rationale:
In end-stage liver disease, the liver cannot break down ammonia by-products of protein metabolism. The increased ammonia levels in the serum cross the blood–brain barrier, causing uncontrolled drowsiness and confusion. Hyperglycemia is characterized by polyphagia, polydipsia, and polyuria, along with fatigue, weight loss, excessive thirst, and abdominal pain. Hypocalcemia is characterized by tetany symptoms. Increased bile production does not cause neurologic symptoms; it is related more to digestion.
What is the primary purpose of giving lactulose to a client with advanced liver disease?
1. To ensure regular bowel movements
2. To prevent bowel obstruction
3. To decrease ammonia levels in the blood
4. To promote clotting
Correct Answer: 3
Rationale:
In a client with end-stage liver disease, lactulose is used to decrease ammonia levels in the blood, thus improving cognition and alertness. Ammonia is eliminated through regular bowel movements that the medication promotes, preventing obstructions. Lactulose is not involved in blood clotting.
The nurse would anticipate which tests to be ordered on a client with a diagnosis of cholelithiasis? Select all that apply.
1. Ultrasound
2. Percutaneous transhepatic cholangiography (PTC)
3. Endoscopic retrograde cholangiopancreatography (ERCP)
4. Liver enzymes
5. Fasting blood glucose
6. Magnetic resonance imaging (MRI)
Correct Answer(s): 1,2,3,4
Rationale:
An ultrasound of the gallbladder is the most common test used to diagnose gallstones. Endoscopic retrograde cholangiopancreatography (ERCP) assists in the visualization of the gallbladder, cystic duct, hepatic duct, and common bile duct. Percutaneous transhepatic cholangiography (PTC) can help detect gallstones and diagnose jaundice. Liver enzymes (ALT, AST, alkaline phosphatase) may be elevated. Fasting blood glucose would be helpful for assessing pancreatic problems; an MRI is not used in the diagnosis of gallbladder stones.
The nurse is making a home visit to a client with hepatitis A virus (HAV). Before assessing the client, the nurse will gather the equipment and perform what action next?
1.
Wipe the bedside table with alcohol preps.
2.
Place the supplies on a clean, convenient work area.
3.
Spread paper towels on the work area and wash hands.
4.
Put on a gown and gloves.
Correct answer:3
Rationale:
Hepatitis A is transmitted via fecal contamination and oral ingestion. It is important to maintain standard precautions before and after client contact. The use of standard precautions should prevent transmission of HAV to the health care worker. Paper towels are used to create a clean area surface and hand hygiene is important. Alcohol preps are not effective. The mask is not appropriate because hepatitis is not spread by respiratory secretions.
Which position is best for the client who has undergone a traditional abdominal cholecystectomy?
1. Side-lying position to prevent aspiration
2. Semi-Fowler's position to facilitate breathing
3. Supine to decrease strain on the incision line
4. Prone to reduce nausea
Correct Answer: 2
Rationale:
A semi-Fowler's position improves lung expansion. The incision for a cholecystectomy is high and may interfere with respiratory exchange. The other positions would probably interfere with respirations.
A new employee at a facility needs to receive the hepatitis B (HBV) vaccine. Which statement reflects accurate understanding of the immunization?
1. "I need to receive six shots—one a month until I show positive antibodies to hepatitis."
2. "Once I receive the hepatitis vaccine, I will be immune to all types of hepatitis."
3. "I will receive three injections over a period of months, which should protect me from hepatitis B."
4. "The hepatitis vaccine is an oral vaccine with live attenuated virus."
Correct answer: 3
Rationale:
The hepatitis vaccine is used to protect health care workers and other individuals from hepatitis B. The series consists of three intramuscular injections, the first two given at least 1 month apart and the third given 4 to 6 months later to provide long-lasting protection from hepatitis B only.
While completing an admission health history, which information would indicate the need for additional screening of hepatitis C virus (HCV)?
1.
States that he experimented with intravenous (IV) drugs while in the armed services overseas
2.
Reports having a blood transfusion last year because of traumatic injury
3.
Explains that his job involves travel to undeveloped countries where he has had exposure to unsanitary conditions
4.
States that he frequently eats out at restaurants
Correct Answer: 1
Rationale:
The nurse should anticipate that client with a history of IV drug use should be tested for hepatitis C virus (HCV). Any blood transfusion given after 1992 does not pose a risk for hepatitis C, because the antibody test for screening transfusions for hepatitis C became available. Hepatitis A virus (HAV) is spread by the oral–fecal route and can be more of a health risk when living in unsanitary conditions or traveling to undeveloped countries. Eating out at restaurants may predispose the person to infectious hepatitis (HAV).
A client has been diagnosed with cholecystitis. What menu selection would be appropriate for this client?
1.
Eggs, bacon, whole grain toast, decaffeinated tea
2.
Fresh fruit, oatmeal, decaffeinated coffee
3.
Roast beef sandwich with Swiss cheese, cranberry juice
4.
Cottage cheese, avocado, bagel, tea
Correct Answer: 2
Rationale:
A low-fat diet is appropriate for the client with cholecystitis. Eggs, bacon, cheese, and avocados are high in fat and should be avoided. Other foods to avoid include whole milk, cream, butter, ice cream, fried foods, rich pastries, gravies, and nuts
What important teaching instructions should the nurse relay to the client before discharge following a laparoscopic cholecystectomy?
1.
Avoid dietary fat for at least 1 year.
2.
Avoid heavy lifting for at least 2 weeks.
3.
Expect bile-colored drainage from the incision.
4.
Resume all activities gradually.
Correct answer: 4
Rationale:
Resuming all activities gradually is the correct answer. A diet low in fat is usually ordered and the client needs to avoid heavy lifting for 4 to 6 weeks. Bile-colored drainage is not to be expected post operative.
Clients with liver disease frequently develop a problem with jaundice. What would the nurse identify as the physiologic cause of jaundice?
1. Increased levels of ammonia
2. Increased alanine aminotransferase (ALT) level
3. Bilirubin levels above 4 mg/dL (68 mcmol/L)
4. Increased red blood cell (RBC) production
Correct Answer: 3
Rationale:
Increased levels of bilirubin (greater than 2.0 mg/dL [34 mcmol/L]) cause a discoloration of the skin called jaundice. The bilirubin value needs to be two to three times the normal level for jaundice to be manifested. Normal value of total bilirubin is 0.2 to 1.3 mg/dL (3.4 to 22.7 mcmol/L). Jaundice occurs because of an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary system. Increased ammonia and ALT levels do not cause jaundice; they are problems associated with the malfunctioning liver. Hemolytic jaundice is caused by an increased red blood cell (RBC) destruction or hemolysis.
A client is admitted with hypothyroidism. What findings would be noted on the admission nursing assessment? Select all that apply.
1. Diarrhea
2. Tachycardia
3. Brittle nails
4. Intolerance to cold
5. Hypotension
6. Shiny, silky hair
Correct Answer(s): 3,4,5
Rationale:
Brittle nails, intolerance to cold; hypotension; bradycardia; dry, coarse, brittle hair; and constipation are common findings with clients who have hypothyroidism. Tachycardia, diarrhea, and shiny, silky hair are common symptoms associated with hyperthyroidism.
A client has been diagnosed with nonalcoholic fatty liver disease (NAFLD). Which of the following is characteristic of the condition? Select all that apply.
1. Caused by excessive ingestion of alcohol.
2. Elevated liver function studies is an early sign.
3. Important client goal is to reduce weight.
4. Associated with clients who have metabolic syndrome.
5. Diagnosed by genetic testing.
Correct Answer(s): 2,3,4
Rationale:
Nonalcoholic fatty liver disease (NAFLD) occurs in clients who do not consume excessive amounts of alcohol. NAFLD should be considered in clients with risk factors such as obesity, diabetes, hyperlipidemia, and hypertension (metabolic syndrome). Elevations in liver function tests (ALT, AST) are often the first sign of NAFLD. Ultrasound and CT scans can be used to diagnose NAFLD. Definitive diagnosis is by a liver biopsy. Treatment goals are to reduce risk factors by reducing body weight, hyperlipidemia, hypertension, and managing diabetes.
The nurse is caring for a client with Addison disease. Which findings indicate the development of a complication of this condition? Select all that apply.
1. Back and abdominal pain
2. Hyperglycemia
3. Extreme weakness
4. Temperature of 101° F (38.3° C)
5. Increased BP
6. Confusion
Correct Answer(s): 1,3,4,6
Rationale:
Addisonian crisis is an acute episode of adrenal insufficiency, which can be a life-threatening emergency. It is characterized by weakness, often accompanied by pain in the back, abdomen, or legs, along with severe manifestations of glucocorticoid and mineralocorticoid deficiency, including hypotension (particularly postural), tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, hyperpyrexia, and confusion. It is treated by administration of hydrocortisone and fluid replacement.
A client has been diagnosed with hyperthyroidism. Which signs and symptoms can the nurse anticipate this client exhibiting? Select all that apply.
1. Tachycardia
2. Weight gain
3. Localized edema
4. Exophthalmos
5. Enlarged thyroid
Correct Answer(s): 1,3,4,5
Rationale:
With hyperthyroidism, there is an increased rate of body metabolism, causing an increase in systolic BP and pulse rate. The heart is working overtime and it becomes hard for the heart to pump, causing localized dependent edema. Exophthalmos, a protrusion or bulging of the eyeballs from the orbits, is caused by impaired venous drainage from the orbit leading to increased deposits of fat and fluid (edema) in the orbital tissues, which increases intraocular pressure behind the eyes. An enlarged thyroid or goiter is often found in Grave disease, iodine deficiency, and Hashimoto thyroiditis. With hyperthyroidism, weight loss is seen despite increased appetite and food intake because of the increase in metabolism. Weight gain is seen with clients who have a diagnosis of hypothyroidism.
Which nursing interventions are appropriate when caring for a client with hyperthyroidism? Select all that apply.
1. Implement salt restriction.
2. Instill artificial tears as needed.
3. Provide several high-calorie meals.
4. Keep the environment warm and quiet.
5. Encourage rest periods throughout the day.
6. Initiate a planned exercise program.
Correct Answer(s): 1,2,3,5,6
Rationale:
Salt restriction can help reduce periorbital edema. The client with hyperthyroidism needs a calm, cool, quiet room, because increased metabolism causes sleep disturbances, so resting throughout the day is important. With the increased metabolic demands on the body, meals that are small and of high caloric content are best. Initiating a planned exercise program involving large muscle groups (tremors can interfere with small-muscle coordination) to allow the release of tension and restlessness is also appropriate. Artificial tears are helpful in preventing drying of the eyes secondary to exopthalmos.