1. Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be
appropriate for a client who is newly diagnosed with Cushing syndrome?
A. Monitor blood glucose levels daily.
B. Increase intake of fluids high in potassium.
C. Encourage adequate rest between activities.
D. Offer the client a sodium-enriched menu.
ANSWER: A. Monitor Blood Glucose Levels
RATIONALE:
CUSHING SYNDROME RESULTS FROM A HYPERSECRETION OF GLUCOCORTICOIDS IN THE ADRENAL CORTEX. CLIENTS WITH
CUSHING SYNDROME OFTEN DEVELOP DIABETES MELLITUS. MONITORING OF SERUM GLUCOSE LEVELS ASSESSES FOR
INCREASED BLOOD GLUCOSE LEVELS SO THAT TREATMENT CAN BEGIN EARLY. A COMMON FINDING IN CUSHING SYNDROME IS
GENERALIZED EDEMA. ALTHOUGH POTASSIUM IS NEEDED, IT IS GENERALLY OBTAINED FROM FOOD INTAKE, NOT BY OFFERING
POTASSIUM-ENHANCED FLUIDS. FATIGUE IS USUALLY NOT AN OVERWHELMING FACTOR IN CUSHING SYNDROME, SO AN
EMPHASIS ON THE NEED FOR REST IS NOT INDICATED A LOW-CALORIE, LOW-CARBOHYDRATE, LOW-SODIUM DIET IS NOT
RECOMMENDED.
2. The nurse is assessing a male client with acute pancreatitis. Which finding requires the most
immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level.
B. While the nurse is taking the client's blood pressure, he has a carpal spasm.
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D. The client states that he will continue to drink alcohol after going home.
ANSWER: B. WHILE THE NURSE IS TAKING THE CLIENT'S BLOOD PRESSURE, HE HAS A CARPAL SPASM.
RATIONALE:
A POSITIVE TROUSSEAU SIGN INDICATES HYPOCALCEMIA AND ALWAYS REQUIRES FURTHER ASSESSMENT AND INTERVENTION,
REGARDLESS OF THE CAUSE (40% TO 75% OF THOSE WITH ACUTE PANCREATITIS EXPERIENCE HYPOCALCEMIA, WHICH CAN
HAVE SERIOUS, SYSTEMIC EFFECTS). A KEY DIAGNOSTIC FINDING OF PANCREATITIS IS SERUM AMYLASE AND LIPASE LEVELS
THAT ARE TWO TO FIVE TIMES HIGHER THAN THE NORMAL VALUE. SEVERE BORING PAIN IS AN EXPECTED SYMPTOM FOR THIS
DIAGNOSIS, BUT DEALING WITH THE HYPOCALCEMIA IS A PRIORITY OVER ADMINISTERING AN ANALGESIC. LONG-TERM
PLANNING AND TEACHING DO NOT HAVE THE SAME IMMEDIATE IMPORTANCE AS A POSITIVE TROUSSEAU SIGN.
3. The nurse is completing an admission interview for a client with Parkinson disease. Which
question will provide additional information about manifestations that the client is likely to
experience?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Do you have frequent blackout spells?"
C. "Have you ever been frozen in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?"
, ANSWER: C. HAVE YOU EVER BEEN FROZEN IN ONE SPOT, UNABLE TO MOVE?"
RATIONALE:
CLIENTS WITH PARKINSON DISEASE FREQUENTLY EXPERIENCE DIFFICULTY IN INITIATING, MAINTAINING, AND PERFORMING
MOTOR ACTIVITIES. THEY MAY EVEN EXPERIENCE BEING ROOTED TO THE SPOT AND UNABLE TO MOVE. PARKINSON DISEASE
DOES NOT TYPICALLY CAUSE OPTION A, B, OR D.
4. The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest
tube insertion for hemothorax. What is the best initial action for the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C. Milk the tube to remove any excessive blood clot buildup.
D. Assess for kinks or dependent loops in the tubing.
ANSWER: D. ASSESS FOR KINKS OR DEPENDENT LOOPS IN THE TUBING.
RATIONALE:
THE LEAST INVASIVE NURSING ACTION SHOULD BE PERFORMED FIRST TO DETERMINE WHY THE DRAINAGE HAS DIMINISHED.
OPTION A IS COMPLETED AFTER ASSESSING FOR ANY PROBLEMS CAUSING THE DECREASE IN DRAINAGE. OPTION B IS NO
LONGER CONSIDERED STANDARD PROTOCOL BECAUSE THE INCREASE IN PRESSURE MAY BE HARMFUL TO THE CLIENT. OPTION
C IS AN APPROPRIATE NURSING ACTION AFTER THE TUBE HAS BEEN ASSESSED FOR KINKS OR DEPENDENT LOOPS.
5. A 77-year-old female client is admitted to the hospital with confusion and anorexia of several
days' duration. She has symptoms of nausea and vomiting and is currently complaining of a
headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's
history related to which medication?
A. Warfarin (Coumadin)
B. Ibuprofen (Motrin)
C. Nitroglycerin (Nitrostat)
D. Digoxin (Lanoxin)
ANSWER: D. DIGOXIN
RATIONALE:
OLDER PERSONS ARE PARTICULARLY SUSCEPTIBLE TO THE BUILDUP OF CARDIAC GLYCOSIDES, SUCH AS DIGOXIN OR DIGITOXIN
(MEDICATIONS DERIVED FROM DIGITALIS), TO A TOXIC LEVEL IN THEIR SYSTEMS. TOXICITY CAN CAUSE ANOREXIA, NAUSEA,
VOMITING, DIARRHEA, HEADACHE, AND FATIGUE. OPTIONS A, B, AND C ARE UNLIKELY TO RESULT IN THE SYMPTOMS
DESCRIBED.
6. The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a
bedridden client with Huntington disease. Which care measure is most important for the nurse
to supervise?
A. Oral care
B.Bathing
C. Foot care
D. Catheter care
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