A nurse is teaching a client who is recovering from a transsphenoidal hypophysectomy. Which statement made by the client indicates a correct understanding of the teaching?
"I must restrict my fluid intake."
"I must avoid deep breathing exercises."
"I must lie flat for 48 hours after surgery."
"I must avoid blowing my nose and bending at the waist."
The Correct Answer is D
A. Fluid intake may need to be monitored, but restricting fluids is not typically advised unless specifically directed by the healthcare provider due to complications like diabetes insipidus.
B. Avoiding deep breathing exercises is not recommended, as these exercises are important for preventing respiratory complications postoperatively.
C. Lying flat for 48 hours after surgery is incorrect; the head of the bed is usually elevated to decrease intracranial pressure and promote healing.
D. Avoiding blowing the nose and bending at the waist is crucial after transsphenoidal hypophysectomy to prevent increased intracranial pressure and avoid disrupting the surgical site, which could lead to complications such as cerebrospinal fluid leakage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: The client’s elevated HbA1c (8.4%) and blood glucose level (235 mg/dL) indicate poorly controlled diabetes mellitus, which is likely leading to their symptoms of fatigue, blurred vision, dizziness, and headache. The client’s history of running out of insulin and glucose strips further supports the diagnosis of Type 1 diabetes mellitus, or possibly poorly controlled Type 2 diabetes mellitus.
Actions to Take:
Teach the client about the signs of hyperglycemia: Given the elevated blood glucose levels and lack of regular monitoring, it is essential to educate the client on recognizing signs of hyperglycemia to prevent complications such as diabetic ketoacidosis.
Assess the client’s feet for sensation: Diabetes can lead to neuropathy, increasing the risk of foot injuries and infections. Regular assessment of foot sensation is vital for early detection and prevention of complications.
Parameters to Monitor:
Fingerstick blood glucose: Frequent monitoring of blood glucose is necessary to assess the effectiveness of the insulin regimen and to make necessary adjustments.
Urinary output: Monitoring urinary output is important because polyuria is a common symptom of hyperglycemia. Decreased urine output may also indicate dehydration or renal impairment, both of which are complications of poorly controlled diabetes.
Correct Answer is A
Explanation
A. Hyperparathyroidism often leads to elevated levels of calcium in the blood, which can result in joint and bone pain due to the excessive breakdown of bone tissue (osteoporosis).
B. Tremors are not typically associated with hyperparathyroidism; they are more commonly linked to conditions like hyperthyroidism or neurological disorders.
C. Swelling in the legs is more commonly associated with conditions like heart failure or venous insufficiency, not hyperparathyroidism.
D. Diarrhea is not a common symptom of hyperparathyroidism; this condition is more likely to cause constipation due to hypercalcemia.
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