EXAM COMPLETE 135 QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) ALREADY GRADED A+ BRAND
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A 42 year-old woman with Ménière's disease is admitted with vertigo, nausea, and vomiting.
Which nursing intervention will be included in the care plan? - CORRECT ANSWER: Dim the
lights in the patient's room.
Rationale: A darkened, quiet room will decrease the symptoms of the acute attack of Ménière's
disease.
A 56-year-old patient who is disoriented and reports a headache and muscle cramps is
hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse
would expect the initial laboratory results to include a(n) - CORRECT ANSWER: Decreased
serum sodium
Rationale: When water is retained, the serum sodium level will drop below normal, causing the
clinical manifestations reported by the patient.
A 61-year-old female patient admitted with pneumonia has a total serum calcium level of 13.3
mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for
_____ levels. - CORRECT ANSWER: Parathyroid hormone
Rationale: Parathyroid hormone is the major controller of blood calcium levels.
A home health nurse is assessing a patient with type 1 DM who has been controlled for 6
months. The nurse is surprised and concerned about a blood glucose reading of 52 mg/dL. What
action by the patient most likely caused this episode of hypoglycemia? - CORRECT ANSWER:
A new 2-hour long exercise class at the gym this morning.
,Rationale: Excessive exercise used up the glucose that was made available by the insulin taken
by the patient. The patient now has too much insulin for the available glucose and has become
hypoglycemic.
A nurse assessing a patient day 1 after a subtotal thyroidectomy notes that the patient's color is
poor, the pulse and respirations are rapid, and the patient feels warm to the touch. The patient
says that she feels frightened. What is the best initial implementation by the nurse? - CORRECT
ANSWER: Call the charge nurse; these are signs of a thyroid storm
Rationale: Call the charge nurse; these signs and symptoms suggest excessive stimulation caused
by an elevated level of thyroid hormones, and the patient needs immediate care.
A nurse explains that type 1 DM is a disease in which the body does not produce enough insulin.
What is the reason that the blood glucose is elevated? - CORRECT ANSWER: Destruction of
beta cells in the pancreas.
Rationale: Type 1 DM is a disease in which the pancreas does not produce adequate insulin b/c
of the destruction of beta cells.
A nurse is caring for a patient diagnosed with Addison disease. Which signs and symptoms
should lead the nurse to suspect adrenal crisis? - CORRECT ANSWER: Confusion and
tachycardia.
Rationale: Confusion and tachycardia are signs that the patient may be in adrenal crisis which is
a medical emergency and should be brought to the attention of the charge nurse.
A nurse is explaining Graves' disease to a newly diagnosed patient. Which statement by the nurse
best clarifies the pathophysiologic changes of Graves' disease? - CORRECT ANSWER: "Your
thyroid gland is overactive, but there are ways to treat it through medicine or surgery."
Rationale: The patient needs to recognize the nurses role in giving accurate, timely information.
, A nurse is taking the blood pressure of a patient who had a total thyroidectomy 2 days earlier
notes that the patient's hand goes into carpopedal spasm. What should the nurse recognize this
movement as an indication of? - CORRECT ANSWER: Hypocalcemia, called the Trousseau
sign
Rationale: The carpopedal spasm is the Trousseau sign, which indicates hypocalcemia; Chvostek
sign also indicates hypocalcemia.
A nurse is teaching a client about ear hygiene and health. Which statement by the client indicates
a need for further teaching? - CORRECT ANSWER: "A soft cotton swab is alright to clean my
ears with"
Rationale: Clients should be taught to avoid not to put anything larger than their fingertip into
their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen
buildup.
A nurse should include which instructions when teaching a patient with repeated hordeolum how
to prevent further infection? - CORRECT ANSWER: Discard all open or used cosmetics applied
near the eyes, eyelids, or eye lashes.
Rationale: Hordeolum (styes) are commonly caused by Staphylococcus aureus which may be
present in cosmetic that the patient is using.
A patient has come into the ED accompanied by a friend who states that the patient had been
acting very strangely and seems confused. The friend states that the patient has DM and takes
insulin. Which signs of hypoglycemia might the nurse assess? - CORRECT ANSWER:
Irritability, anxiety, confusion, and dizziness
Rationale: When BS levels fall, hormones are activate to increase serum glucose. One of the
hormones is epinephrine, which causes these symptoms