When assessing a client for an endocrine dysfunction, which question should the nurse ask?- Nurselytic

Question 1 of 5

When assessing a client for an endocrine dysfunction, which question should the nurse ask?

A. "Have you noticed any pain in your legs when walking?" B. "Have you had any unexplained weight loss?" C. "Have you noticed any change in your bowel movements?" D. "Have you experienced any joint pain or discomfort?"

Correct Answer: B

Rationale: The correct answer is B: "Have you had any unexplained weight loss?" Unexplained weight loss can be a common symptom of various endocrine disorders, such as hyperthyroidism and diabetes. This weight loss is often despite an adequate or increased appetite. Choices A, C, and D are less likely to be directly associated with endocrine dysfunction. Pain in the legs when walking could be related to musculoskeletal issues, changes in bowel movements may suggest gastrointestinal concerns, and joint pain is more commonly linked to rheumatologic conditions rather than primary endocrine disorders.

Question 2 of 5

The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?

A. Frequent aspirin (acetylsalicylic acid) and a non-narcotic analgesic B. Motrin (ibuprofen), an NSAID, PRN C. Demerol (meperidine), a narcotic analgesic, every four (4) hours D. Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN

Correct Answer: D

Rationale: In a sickle cell crisis, morphine is the preferred analgesic due to its potency and effectiveness in managing severe pain. Choice A is incorrect because aspirin is contraindicated in sickle cell disease due to its potential to cause a further decrease in blood flow. Choice B, Motrin (ibuprofen), is also not the ideal choice as NSAIDs can exacerbate renal complications in sickle cell patients. Choice C, Demerol (meperidine), is not recommended for sickle cell pain management due to its toxic metabolite accumulation which can cause seizures and other complications.

Question 3 of 5

The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client's neurological status should include which of the following? (Select all that apply)

A. Obtain the pulses in all four extremities B. Ask the client to grasp and squeeze two fingers on each of the nurse's hands C. Determine the client's orientation to person, place, and time D. B, C

Correct Answer: D

Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.

Question 4 of 5

The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress

Correct Answer: C

Rationale: The correct method described in option C helps maintain spinal alignment while moving from a lying to a standing position, which is crucial after a lumbar laminectomy with spinal fusion. This technique minimizes strain on the back and promotes safe movement. Choices A, B, and D involve movements that could potentially strain the back, increase the risk of injury, or compromise the spinal alignment, making them less optimal for the client recovering from such surgery.

Question 5 of 5

The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

A. Encouraging family discussion of feelings B. Accepting the family's experience of anger C. Facilitating the use of spiritual practices identified by the family D. All of the above

Correct Answer: D

Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.

Nurselytic

ATI RN

ATI RN

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