A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:

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Question 1 of 5

A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:

Correct Answer: C

Rationale: Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of dilute urine, resulting in fluid volume deficit. The posterior pituitary tumor in this case is likely causing decreased secretion of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine and retain water. This imbalance results in the loss of fluid, leading to dehydration and electrolyte imbalances. Therefore, the most appropriate nursing diagnosis for this client is fluid volume deficit, as the priority is to address the dehydration and restore fluid balance to prevent further complications.

Question 2 of 5

Which of the following instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave's disease?

Correct Answer: C

Rationale: Regular follow-up care is crucial after a thyroidectomy for Grave's disease to monitor the patient's thyroid hormone levels, assess for signs of complications such as hypothyroidism or hypoparathyroidism, and ensure appropriate management of any related conditions. Routine follow-up visits with healthcare providers allow for ongoing assessment and adjustment of medications, as well as addressing any concerns the patient may have post-surgery. By emphasizing the importance of regular follow-up care, the healthcare team can provide necessary support and guidance to the patient throughout their recovery process.

Question 3 of 5

The nurse is caring for a client who's hypoglycemic. This client will have a blood glucose level:

Correct Answer: A

Rationale: Hypoglycemia is defined as a blood glucose level below 70mg/dl. When a client is experiencing hypoglycemia, it means their blood sugar is lower than the normal range and can lead to symptoms such as sweating, tremors, confusion, and even loss of consciousness. It is important for nurses to recognize and treat hypoglycemia promptly to prevent serious complications.

Question 4 of 5

Appropriate nursing interventions for J.E. would be

Correct Answer: A

Rationale: For J.E., who suffered head injuries in a motor vehicle accident, appropriate nursing interventions should focus on holistic care to prevent complications and promote recovery. Option A includes skin care and position changes every 2 hours (q2h) and as needed, which is crucial for preventing pressure injuries in the immobile patient. Maintaining alignment of extremities helps prevent muscle contractures. Respiratory exercises are essential for preventing atelectasis and improving lung function in patients at risk for pneumonia due to decreased mobility. These interventions address the immediate needs of the patient and aim to prevent further complications related to immobility and head injury. Options B, C, and D lack the comprehensive approach to care provided in option A, making it the most appropriate choice for J.E.

Question 5 of 5

The nurse is aware that in communicating with an elderly client, the nurse will

Correct Answer: B

Rationale: When communicating with an elderly client, it is important to use a low-pitched voice because high frequencies can be difficult for older individuals to hear. A low-pitched voice is easier for them to understand and can help enhance communication. Speaking clearly and directly in a calm manner with a lower pitch can make it easier for the elderly client to hear and comprehend what is being said. Additionally, it is important to speak at a moderate pace and volume to ensure effective communication with elderly clients.

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