NUR 213 Final - On which areas should the nurse focus when asse...

NUR 213 Final

• A client is experiencing health problems related to alterations in adrenal medulla function.

On which areas should the nurse focus when assessing this client?Select all that apply.

• Heart rate
• Weight
• Respiratory rate
• Skin integrity
• Blood pressure

Answer

A, B, C, E

Explanation

The adrenal medulla secretes the catecholamines of epinephrine and norepinephrine. These hormones stimulate the heart, increase metabolism, increase respiration, and constrict blood vessels. The nurse should focus the assessment on heart rate, weight, respiratory rate, and blood pressure. Skin integrity is not influenced by these hormones.

• The nurse is teaching an in-service about metabolic disorders. Which per- son is at the

greatest risk for malnutrition as a result of hypermetabolism?

• A client with chronic obstructive pulmonary disease
• A client with osteoporosis
• A client who is a vegetarian
• A client who has dysphagia

Answer A Explanation

The client with chronic obstructive pulmonary disease often is malnourished because of the increased caloric need associated with breathing efforts. The client with dysphagia is at risk for malnutrition because of the inability to eat adequate amounts of foods. Patients with osteoporosis do not have higher metabolic rates.There is no connection between hypermetabolism and vegetarianism.

• The nurse is assessing the vital signs of a client experiencing hypoparathyroidism. While

monitoring the blood pressure, the nurse notes the client's hand begins to spasm. How should the nurse document this assessment finding?

• Trousseau sign 1 / 2

• Chvostek sign
• Turner's sign
• Cullen's sign

Answer A Explanation

Trousseau sign is elicited when placing a blood pressure cuff on the arm; when the cuff is inflated, the client experiences carpal spasms. Chvostek sign is elicited by tapping on the face in front of the ear and observing for contractions of the muscle. Turner's sign and Cullen's sign are both associated with retroperitoneal bleeding.

• While performing an endocrine assessment on a client suspected of having Cushing disease,

the nurse asks the female client if she has experienced recent weight changes. Which endocrine systems is the nurse assessing? Select all that apply.

• Gonads
• Pituitary gland
• Thyroid gland
• Adrenal gland
• Parathyroid gland

Answer

B, C, D

Explanation

In adrenal, thyroid, and pituitary disease, the client's weight changes might provide information as to the endocrine disorder the client is experiencing. The client might gain weight with an adrenal disorder such as Cushing disease, or thyroid disease such as hypothyroidism or hyperthyroidism.The pituitary gland controls ADH, which influences water absorption by the renal tubules. The parathyroid gland regulates calcium and phosphorous. The gonads influence estrogen and androgens.

• The nurse is reviewing the laboratory test results for a client with an en- docrine disorder.

For which tests should the nurse expect to have current values on the medical record?Select all that apply.

• Prothrombin time
• Albumin
• / 2