SOLVED

 Question 11 A patient was severely injured when a building exploded. The patient’s pain level report does not seem to reflect the severity of these injuries. How would the nurse evaluate this response? 1. The patient is in shock and cannot respond to painful stimuli. 2. Someone at the scene must have given the patient pain medication. 3. The patient has increased endogenous opioids. 4. The patient does not understand the severity of the injuries. Question 12 Because a patient is experiencing the fight-or-flight stage of the stress response, the nurse would be least concerned about which laboratory finding? 1. Serum glucose 80 mg/L 2. Serum potassium 3.3 mEq/L 3. Serum sodium 148 mEq/L 4. Total bilirubin 2.4 mg/dL Question 13 A patient is still hypermetabolic two weeks after his injury. What finding would the nurse expect? 1. Muscle wasting 2. Low serum BUN levels 3. Hypoglycemia 4. Decreased level of consciousness Question 14 A patient who is being mechanically ventilated has been prescribed hydrocortisone for treatment of adrenal insufficiency. Which nursing intervention should be implemented? 1. Range of motion exercising 2. Expect urine to be cloudy 3. Increase monitoring for thrombus development 4. Mix all IV medications in D5W for administration Question 15 A patient who is receiving taper doses of hydrocortisone has been taking oral medication for 3 days. This morning the patient has assessment findings of recurrent adrenal insufficiency. What nursing action, if any, is indicated? 1. These symptoms may come and go for several days, so no action is necessary. 2. Discuss this assessment with the primary health care provider. 3. Give a dose of methylprednisolone instead of hydrocortisone. 4. Give the next hydrocortisone by IV. Question 16 The nurse has established the nursing diagnosis of Risk for Decreased Cardiac Output for a patient who has hyperthyroidism. Which interventions are indicated to address this diagnosis? 1. Monitor for development of peripheral edema. 2. Keep room warm. 3. Provide medications to manage pain. 4. Frequently reassure and calm the patient. 5. Monitor activity tolerance. Question 17 A patient is receiving radiation treatment for laryngeal cancer. Which ECG change would the nurse evaluate as indicating need to assess this patient for hypothyroidism? 1. Inverted T wave 2. Shortened PR interval 3. P wave inversion 4. Atrial fibrillation Question 18 Which nursing interventions are indicated to support the outcome of “maintain normal body temperature” for a patient with hyperthyroidism? 1. Keep room door closed. 2. Provide an additional blanket. 3. Consider a cooling blanket if fever is greater than 102°F. 4. Place a scarflike covering over the patient’s head. Question 19 A nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The patient is not known to have diabetes, but initial non-fasting blood sugar is 140 mg/dL. At which point would the nurse expect insulin therapy to begin? 1. When fasting blood sugar exceeds 110 mg/dL 2. When the patient shows assessment findings associated with hyperglycemia 3. If another random blood glucose is in the same range as this initial reading 4. When fasting blood glucose levels reach 180 mg/dL Question 20 The nurse realizes that increased interventions to prevent infection are necessary when the patient is under stress. Which effect of cortisol complicates this risk? 1. Increased release of histamines 2. Increased production of eosinophils 3. Causing a shift to the left 4. Increasing serum sodium levels