ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 50 : Caring for Clients With Disorders of the Endocrine System Questions
Question 1 of 5
The nurse is caring for a client with hypoparathyroidism. When the nurse taps the client's facial nerve, the client's mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels?
Correct Answer: A
Rationale: If a nurse taps the client's facial nerve (which lies under the tissue in front of the ear), the client's mouth twitches and the jaw tightens. The response is identified as a positive Chvostek sign. A positive Trousseau sign is elicited by placing a BP cuff on the upper arm, inflating it between the systolic and diastolic BP, and waiting 3 minutes. The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Positive Babinski sign is elicited by stroking the sole of the foot. Paresthesia is not a symptom that can be elicited; it is felt by the client.
Question 2 of 5
A client with severe hypoparathyroidism is experiencing tetany. What medication, prescribed by the physician for emergency use, will the nurse administer to correct the deficit?
Correct Answer: C
Rationale: Tetany and severe hypoparathyroidism are treated immediately by the administration of an IV calcium salt, such as calcium gluconate. The other medications are not effective for the treatment of calcium deficit.
Question 3 of 5
The nurse is teaching a client about the dietary restrictions related to a diagnosis of hyperparathyroidism. What foods should the nurse encourage the client to avoid?
Correct Answer: D
Rationale: Clients with hyperparathyroidism should use a low-calcium diet (fewer dairy products) and drink at least 3 to 4 L of fluid daily to dilute the urine and prevent renal stones from forming. It is especially important that the client drink fluids before going to bed and periodically throughout the night to avoid concentrated urine. Bananas, chicken livers, and hamburgers do not require avoidance. Milk is the highest in calcium content.
Question 4 of 5
A client is receiving a test to determine adrenal function. What medication does the nurse administer as a screening test?
Correct Answer: A
Rationale: A dose of synthetic ACTH, cosyntropin, is administered intramuscularly as a screening test for adrenal function. The other medications are not screening medications to determine adrenal function.
Question 5 of 5
The nurse is instructing a client about taking corticosteroid therapy for adrenal insufficiency. What statement made by the client indicates a need for further instruction?
Correct Answer: A
Rationale: The nurse should explain adrenal insufficiency and the importance of lifetime corticosteroid replacement. The other statements indicate that the client is educated about medication administration.