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Rationale 4: Pressing on the patient’s shoulders will not elicit findings associated with hypocalcemia.Rationale 5: Having the patient count backwards is not significant to hypocalcemia.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 46-2Question 26Type: MCMAFollowing surgery for hypersecretion of growth hormone, a patient complains of a supraorbital headache. The nurse suspects a possible CSF leak and would take which actions?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. Test any nasal drainage for glucose.2. Maintain bed rest.3. Inform the patient that headaches are expected.4. Keep the head of the bed (HOB) elevated 30 degrees.5. Administer antibiotics as ordered.Correct Answer: 1,2,4,5Rationale 1: The presence of glucose in nasal drainage indicates leakage of CSF.Rationale 2: Postoperative care of patients with a potential CSF leak should include bed rest.
Rationale 3: Headaches are not expected after surgery and are a sign of a CSF leak.Rationale 4: Postoperative care of patients with a CSF leak should include continued elevation of the HOB.Rationale 5: Postoperative care of patients with a CSF leak should include the administration of prophylactic antibiotics.Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: ImplementationLearning Outcome: 46-2Question 27Type: MCMAThe nurse is planning to present a community education session on advances in the diagnosis and treatment of endocrine disorders. Which topics should be included in this presentation?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. More sensitive technology for hormonal assays2. Development of new synthetic hormones3. Standardized methods to prevent endocrine disorders4. New diagnostic imaging technologies5. Improvements in surgical techniquesCorrect Answer: 1,2,4,5Rationale 1: Significant advances have been made in the diagnosis and treatment of endocrine disorders in recent years due to the development of more sensitive hormonal assays.Rationale 2: Several new synthetic hormones have been developed.Rationale 3: Therapy for endocrine disorders is limited to early diagnosis and improved treatment. Prevention is not yet possible.Rationale 4: Diagnostic imaging technologies continue to advance.Rationale 5: There have been significant advances in surgical techniques for endocrine disorders.
Global Rationale: Cognitive Level: ApplyingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: PlanningLearning Outcome: 46-5Question 28Type: MCSAWhen measuring the blood pressure of a patient with hypoparathyroidism, the nurse notes spasms of the patient’s hand. How should the nurse document this finding?