Nursing Elites

1. Following a unilateral adrenalectomy, Nurse Betty would assess for hyperkalemia indicated by which of the following signs?

• A. Muscle weakness
• B. Tremors
• C. Diaphoresis
• D. Constipation

Correct answer: A

Rationale: Muscle weakness is a classic manifestation of hyperkalemia, an elevated level of potassium in the blood. After an adrenalectomy, where one adrenal gland is removed, there may be a risk of hyperkalemia due to altered hormone regulation. Tremors (Choice B) are not typically associated with hyperkalemia but may be seen in conditions like hypocalcemia. Diaphoresis (Choice C) and constipation (Choice D) are not specific indicators of hyperkalemia. Diaphoresis is excessive sweating and constipation is a common gastrointestinal issue, neither directly related to potassium imbalances.

2. The healthcare provider is assessing a client with suspected diabetes insipidus. Which of the following clinical manifestations would support this diagnosis?

• A. Polyuria and polydipsia
• B. Hypertension and bradycardia
• C. Weight gain and edema
• D. Oliguria and thirst

Correct answer: A

Rationale: Polyuria (excessive urination) and polydipsia (excessive thirst) are classic clinical manifestations of diabetes insipidus. In this condition, there is a deficiency of antidiuretic hormone, leading to the inability of the kidneys to concentrate urine effectively, resulting in increased urine output (polyuria) and consequent thirst (polydipsia). Hypertension and bradycardia (Choice B) are not typical findings in diabetes insipidus. Weight gain and edema (Choice C) are more indicative of conditions such as heart failure or nephrotic syndrome. Oliguria (decreased urine output) and thirst (Choice D) are contradictory symptoms to what is seen in diabetes insipidus.

3. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

• A. Weight loss
• B. Flat neck and hand veins
• C. An increase in blood pressure
• D. A decreased central venous pressure (CVP)

Correct answer: C

Rationale: An increase in blood pressure is a common sign of fluid volume excess in clients with congestive heart failure due to the increased amount of fluid in the vascular system. Weight loss (Choice A) is not typically associated with fluid volume excess. Flat neck and hand veins (Choice B) are signs of fluid volume deficit, not excess. A decreased central venous pressure (CVP) (Choice D) is not expected in a client with fluid volume excess.

4. The nurse is caring for a client with diabetes insipidus. Which of the following laboratory findings should the nurse monitor?

• A. Serum sodium
• B. Serum potassium
• C. Serum calcium
• D. Serum magnesium

Correct answer: A

Rationale: In diabetes insipidus, there is excessive excretion of water leading to dehydration. Monitoring serum sodium levels is crucial because these clients often experience hypernatremia (elevated serum sodium levels) due to the loss of relatively more water than sodium, resulting in a sodium concentration imbalance. While monitoring serum potassium, calcium, and magnesium levels is also important in various conditions, they are not the primary focus in diabetes insipidus.

5. The healthcare provider is caring for a client with Cushing's syndrome. Which of the following nursing interventions is appropriate?

• A. Monitor blood glucose levels
• B. Restrict fluid intake
• C. Administer potassium supplements
• D. Encourage a high-protein diet

Correct answer: A

Rationale: Clients with Cushing's syndrome are at risk for hyperglycemia due to the effects of cortisol on glucose metabolism. Monitoring blood glucose levels is crucial to detect and manage hyperglycemia promptly. Restricting fluid intake (choice B) is not necessary unless specifically indicated for another condition, as clients with Cushing's syndrome are prone to fluid imbalances. Administering potassium supplements (choice C) is not appropriate as clients with Cushing's syndrome often have elevated potassium levels due to the effects of cortisol. Encouraging a high-protein diet (choice D) is not recommended as clients with Cushing's syndrome should focus on a balanced diet to manage their condition effectively.

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