A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)
Hepatomegaly
Moon face
Coarse facia features
Enlarged distal extreme
Loss of color discrimination
Correct Answer : A,C,D,E
A: Hepatomegaly is a common manifestation of acromegaly, as excess growth hormone can cause organ enlargement.
B: Moon face is associated with Cushing's syndrome, not acromegaly. In acromegaly, facial changes are characterized by bony enlargement and coarsening of features, not the rounded face seen in Cushing's syndrome.
C: Coarse facial features are a classic sign of acromegaly due to the overgrowth of facial bones and soft tissue, leading to prominent brows, a larger nose, and a protruding jaw.
D: Enlarged distal extremities, such as hands and feet, are typical in acromegaly because of excessive growth hormone, which affects the growth plates in the bones and causes an increase in size and thickness.
E: This can occur due to optic nerve involvement, which is associated with pituitary tumors that can cause acromegaly. Vision changes, including loss of color discrimination, may be noted as a result of pressure on the optic chiasm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
One gram is equal to 1000 milligrams, and one teaspoon is equal to 5 milliliters. Therefore, the nurse can use the following formula:
0.4 g x 1000 mg/g x 5 mL/100 mg x 1 tsp/5 mL = 2 tsp
The nurse will instruct the client to take two teaspoons of cough syrup every four hours as prescribed by the primary health-care provider.
Correct Answer is B
Explanation
A. Obtaining a culture of the drainage may be necessary, but the immediate concern is to determine if the drainage is cerebrospinal fluid (CSF) or another type of fluid. Checking for glucose content is a rapid way to differentiate CSF from other fluids.
B. Correct. Clear drainage from the nose post-transsphenoidal hypophysectomy may indicate a CSF leak, which is a potential complication. Checking the drainage for glucose can help differentiate CSF from other fluids, as CSF contains glucose. If the drainage tests positive for glucose, it indicates the presence of CSF.
C. Documenting the amount of drainage is important, but determining the nature of the drainage (CSF or other fluid) takes precedence in this situation.
D. Notifying the client's provider is important, but the nurse should gather information about the drainage first by checking for glucose content. This information will be crucial for the healthcare provider to make decisions about further interventions
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