ANSWERS AND RATIONALES

EXAM CODE HAAD2

1. Answer: D
Rationale: Weighing everyday is the most accurate means in monitoring
the hydration status.

2. Answer: B
Rationale: Administration of thyroid hormone will prevent problems. Early
identification and continued treatment with hormone replacement corrects
this condition.
3. Answer: B
Rationale: Peripheral neuropathy can lead to lack of sensation in the
lower extremities. Clients do not feel pressure and/or pain and are at
high risk for skin impairment.

4. Answer: D
Rationale: In diabetic patients, the nurse should watch out for signs of
hypoglycemia manifested by dizziness, tremors, weakness, pallor
diaphoresis and tachycardia. When this occurs in a conscious client, he
should be given immediately carbohydrates in the form of fruit juice,
hard candy, honey or, if unconscious, glucagons or dextrose per IV.

5. Answer: D
Rationale: posterior neck fat pad and thin extremities. Buffalo hump is
the accumulation of fat pads over the upper back and neck. Fat may also
accumulate on the face. There is truncal obesity but the extremities are
thin. All these are noted in a client with Cushing’s syndrome.

6. Answer: A
Rationale: Deflate the esophageal balloon. When a client with a
Sengstaken-Blakemore tube develops difficulty of breathing, it means the
tube is displaced and the inflated balloon is in the oropharynx causing
airway obstruction

7. Answer: A
Rationale: The largest source of ammonia is the enzymatic and bacterial
digestion of dietary and blood proteins in the GI tract. A protein-
restricted diet will therefore decrease ammonia production.

8. Answer: C
Rationale: Pain in acute pancreatitis is caused by irritation and edema of
the inflamed pancreas as well as spasm due to obstruction of the
pancreatic ducts. Demerol is the drug of choice because it is less likely
to cause spasm of the Sphincter of Oddi unlike Morphine which is
spasmogenic.

9. Answer: A
Rationale: Following surgery of the thyroid gland, bleeding is a potential
complication. This can best be assessed by checking the back and the
sides of the operative dressing as the blood may flow towards the side
and back leaving the front dry and clear of drainage.

10. Answer: C

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Rationale: Propranolol (Inderal) is a beta-adrenergic blocker that controls

the cardiovascular manifestations brought about by increased secretion of
the thyroid hormone in Grave’s disease.

11. Answer: C
Rationale: Lipodystrophy is the development of fibrofatty masses at the
injection site caused by repeated use of an injection site. Injecting
insulin into these scarred areas can cause the insulin to be poorly
absorbed and lead to erratic reactions.

12. Answer: C
Rationale: Progressive weight gain
Hypothyroidism, a decrease in thyroid hormone production, is characterized
by hypometabolism that manifests itself with weight gain.

13. Answer: C
Rationale: Keep legs elevated on 2 pillows while sleeping. The client with
DM has decreased peripheral circulation caused by microangiopathy.
Keeping the legs elevated during sleep will further cause circulatory
impairment.

14. Answer: A
Rationale: Metabolic acidosis is anaerobic metabolism caused by lack of
ability of the body to use circulating glucose. Administration of insulin
corrects this problem.

15. Answer: A
Rationale: Enlarged cirrhotic liver impinges the portal system causing
increased hydrostatic pressure resulting to ascites.

16. Answer: D
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes
metabolic alkalosis because of the loss of hydrochloric acid which is a
potent acid in the body.

17. Answer: A
Rationale: Sodium, which is concerned with the regulation of extracellular
fluid volume, it is lost with vomiting. Chloride, which balances cations in
the extracellular compartments, is also lost with vomiting, because sodium
and chloride are parallel electrolytes, hyponatremia will accompany

18. Answer: A
Rationale: The thyroid gland is symmetrical, non-tender, and palpable only
if the patient has goiter. The palpable mass on the neck is the thyroid
cartilage. It is present in both males and females but is larger in males;
it develops during puberty

19. Answer: C
Rationale: Hypothyroidism causes a decrease in thyroid hormones, which in
turn causes decreased metabolism. Options A, B and D are all consistent
with decreased metabolism. Option C is a symptom of increased
metabolism found in hyperthyroidism.

20. Answer: A

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Rationale: Options B, C and D are all symptoms of hypoglycemia:

nightmares due to depression, weakness (extreme fatigue) and diaphoresis.
Option A is one of the 3 P’s of hyperglycemia: Polydipsia [excessive
thirst], Polyphagia [excessive hunger], and Polyuria [excess urine output].

21. Answer: C
Rationale: Avoid using a sleeping mask at night. The mask may irritate or
scratch the eye if the client turns and lies on it during the night.

22. Answer: B
Rationale: A tracheostomy set and oxygen. Acute respiratory obstruction in
the post-operative period can result from edema, subcutaneous bleeding
that presses on the trachea, nerve damage, or tetany.

23. Answer: B
Rationale: Eating habits are altered. For weight reduction to occur and
be maintained, a new dietary program, with a balance of foods from the
basic four food groups, must be established and continued

24. Answer: A
Rationale: Increase her lean body mass. Increased exercise builds
skeletal muscle mass and reduces excess fatty tissue.

25. Answer: B
Rationale: An occupational therapist can assist a client to improve the
fine motor skills needed to prepare an insulin injection.

26. Answer: D
Rationale: Aluminum hydroxide binds dietary phosphorus in the GI tract
and helps treat hyperphosphatemia. All the other medications mentioned
help treat hyperkalemia and its effects.

27. Answer: B
Rationale: A small part of the gland is left intact. Remaining thyroid
tissue may provide enough hormones for normal function. Total
thyroidectomy is generally done in clients with Thyroid Cancer.

28. Answer: C
Rationale: If the recurrent laryngeal nerve is damaged during surgery, the
client will be hoarse and have difficulty speaking.

29. Answer: B
Rationale: Dry skin is most likely caused by decreased glandular function
and fatigue caused by decreased metabolic rate. Body functions and
metabolism are decreased in hypothyroidism.

30. Answer: C
Rationale: Classic signs associated with hyperthyroidism are weight loss
and restlessness because of increased basal metabolic rate. Exopthalmos is
due to peribulbar edema.

31. Answer: D
Rationale: “Buffalo hump” is the accumulation of fat pads over the upper
back and neck. Fat may also accumulate on the face. There is truncal
obesity but the extremities are thin. All these are noted in a client with
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Cushing’s syndrome.

32. Answer: D
Rationale: In diabetic patients, the nurse should watch out for signs of
hypoglycemia manifested by dizziness, tremors, weakness, pallor
diaphoresis and tachycardia. When this occurs in a conscious client, he
should be given immediately carbohydrates in the form of fruit juice,
hard candy, honey or, if unconscious, glucagons or dextrose per IV.

33. Answer: C
Rationale: Lipodystrophy is the development of fibrofatty masses at the
injection site caused by repeated use of an injection site. Injecting
insulin into these scarred areas can cause the insulin to be poorly
absorbed and lead to erratic reactions.

34. Answer: A
Rationale: Following surgery of the thyroid gland, bleeding is a potential
complication. This can best be assessed by checking the back and the
sides of the operative dressing as the blood may flow towards the side
and back leaving the front dry and clear of drainage.

35. Answer: A
Rationale: Humulin N peaks in 6–8 hours, making the client at risk for
hypoglycemia around midnight, which is why the client should receive a
bedtime snack. This snack will prevent nighttime hypoglycemia.

36. Answer: B
Rationale: Biguanide medication must be held for a test with contrast
medium because it increases the risk of lactic acidosis, which leads to
renal problems

37. Answer: A
Rationale: The short-term goal must address the
part of the nursing diagnosis, which is “high risk for hyperglycemia,”
and this blood glucose level is within acceptable ranges for a client who
is noncompliant.

38. Answer: B
Rationale: The client’s level of consciousness can be altered because of
dehydration and acidosis.
If the client’s sensorium is intact, the client is getting better and
responding to the medical treatment.

39. Answer: A
Rationale: The initial fluid replacement is O.9%normal saline (an isotonic
solution) intravenously, followed by 0.45% saline. The rate depends on the
client’s fluid volume status and physical health, especially that of the
heart.

40. Answer: C
Rationale: Illness increases blood glucose levels; therefore the client must
take insulin and drink high-carbohydrate fluids such as regular Jell-O,
regular popsicles, and orange juice.

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41. Answer: B
Rationale: The client will not be compliant with the diet if he or she is
still hungry. Therefore, the nurse should request the dietician to talk to
the client to try and adjust the meals so that the client will adhere to
the diet.

42. Answer: D
Rationale: When the glucose level is decreased to around 300 mg/dL, the
regular insulin infusion therapy is decreased. Subcutaneous insulin will be
administered per sliding scale.

43. Answer: C
Rationale: Multifocal PVCs, which are secondary to
hypokalemia and which can occur in clients with DKA, are an emergency
and can be life threatening. This client needs an experienced nurse.

44. Answer: C
Rationale: Dry mucous membranes are a result of the hyperglycemia and
occur with both HHS and DKA.

45. Answer: C
Rationale: Narcotic addiction is related to the frequent, severe pain
episodes that often occur with chronic pancreatitis and its complications
and that require narcotics for relief.

46. Answer: B
Rationale: Autodigestion of the pancreas results in severe epigastric pain,
accompanied by nausea, vomiting, abdominal tenderness, and muscle
guarding.

47. Answer: A
Rationale: The nurse should assume the client is hypoglycemic and
administer IVP dextrose, which will rouse the client immediately. If the
collapse is the result of hyperglycemia, this additional dextrose will not
further injure the client.

48. Answer: C
Rationale: Regular insulin peaks in 2–4 hours. Therefore, the nurse should
think about the possibility that the client is having a hypoglycemic
reaction and should assess the client. The nurse should not delegate
nursing tasks to an assistant if the client is unstable.

49. Answer: C
Rationale: A necrotic big toe indicates “dead” tissue.
The client does not feel pain in the lower extremity and does not realize
there has been an injury and therefore does not seek treatment.
Increased blood glucose levels decrease oxygen supply that is needed to
heal the wound and increase the risk for developing an infection.

50. Answer: D
Rationale: All clients who exercise should perform warm-up and cool down
exercises to help prevent muscle strain and injury.

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51. Answer: C
Rationale: The most common precipitating factor is infection. The
manifestations may be slow to appear, with onset ranging from 24 hours
to 2 weeks.

52. Answer: B
Rationale: Client advocacy focuses support on the client’s autonomy. Even
if the nurse disagrees with his living on the street, it is the client’s
right. Arranging for someone to give him his insulin provides for his
needs and allows his choices.

53. Answer: A
Rationale: Age-related visual changes and diabetic retinopathy occur that
could lead to the client having difficulty in reading and drawing up
insulin dosage accurately.

54. Answer: C
Rationale: This result parallels a serum blood glucose level of
approximately 180 to 200 mg/dL.
An A1c is a blood test that reflects average blood glucose levels over a
period of 2–3 months; clients with elevated blood glucose levels are at
risk for developing long-term complications.

55. Answer: C
Rationale: Steatorrhea (fatty, frothy, foul-smelling stool) is caused by a
decrease in pancreatic enzyme secretion and indicates impaired digestion
and possibly an increase in the severity of the pancreatitis. The client
should see the HCP.

56. Answer: A
Rationale: Pancreatic enzymes must be administered with meals to
enhance the digestion of starches and fats in the gastrointestinal tract.

57. Answer: A
Rationale: Pancreatic enzymes enhance the digestion
of starches (carbohydrates) in the gastrointestinal
tract by supplying an exogenous
(outside) source of the pancreatic enzymes
protease, amylase, and lipase.

58. Answer: C
Rationale: The gag reflex will be suppressed as a result of the local
anesthesia applied to the throat to insert the endoscope into the
esophagus; therefore, the gag reflex must be assessed prior to allowing
the client to resume eating or drinking.

59. Answer: C
Rationale: The client should be NPO after midnight to make sure the
stomach is empty to reduce the risk of aspiration during the procedure.

60. Answer: B
Rationale: High-fat and spicy foods stimulate gastric and pancreatic
secretions and may precipitate an acute pancreatic attack.

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61. Answer: B
Rationale: The client in DKA loses potassium from increased urinary
output, acidosis, catabolic state, and vomiting. Replacement is essential
for preventing cardiac dysrhythmias secondary to hypokalemia.

62. Answer: D
Rationale: This ABG indicates metabolic acidosis, which is what is
expected in a client that is in diabetic ketoacidosis. Normal ABGs are pH
7.35–7.45; PaO2 80–100; PaCO2 35–45; HCO3 22–26.

63. Answer: C
Rationale: This fetal position decreases pain caused by stretching of the
peritoneum as a result of edema.

64. Answer: D
Rationale: The client will be NPO, which will decrease stimulation of the
pancreatic enzymes, which will result in decreased autodigestion of the
pancreas, therefore decreasing pain.

65. Answer: C
Rationale: Serum amylase increases within 2 to 12 hours of the onset of
acute pancreatitis to 2 to 3 times normal and returns to normal in 3 to
4 days; lipase elevates and remains elevated for 7 to 14 days.

66. Answer: A
Rationale: Cushing’s syndrome/disease predisposes the client to develop
infections as a result of the immunosuppressive nature of the disease.

67. Answer: C
Rationale: Smoking stimulates the pancreas to releasepancreatic enzymes
and should be stopped.

68. Answer: A
Rationale: The client will have an elevated sodium level as a result of
low circulating blood volume. The fluid is being lost through the urine.
Diabetes means “to pass through” in Greek, indicating polyuria, a symptom
shared with diabetes mellitus. Diabetes insipidus is a totally separate
disease process.

69. Answer: C
Rationale: Bronze pigmentation of the skin, particularly of the knuckles
and other areas of skin creases, occurs in Addison’s disease.
Hypotension and anorexia also occur with Addison’s.

70. Answer: B
Rationale: The adrenal gland secretes cortisol and thepituitary gland
secretes adrenocorticotropic hormone (ACTH), a hormone used by the body
to stimulate the production of
cortisol.

71. Answer: C
Rationale: The client is deprived of all fluids, and if the client has DI
the urine production will not diminish. Vital signs and weights are taken
every hour to determine circulatory status. If a marked decrease in
weight or vital signs occurs, the test is immediately terminated.

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72. Answer: C
Rationale: This is information given to all surgical clients on discharge.

73. Answer: C
Rationale: This is an intervention that will allow the client to discuss
feelings of body image.

74. Answer: B
Rationale: Cancer of the pancreas has a poor prognosis for most clients,
and the nurse should determine if the client has executed an advance
directive regarding their wishes.

75. Answer: A
Rationale: Clients diagnosed with Addison’s disease have adrenal gland
hypofunction. The hormones normally produced by the gland must be
replaced. Steroids and androgens are produced by the adrenal gland.

76. Answer: D
Rationale: Almost all of the iodine that enters the body is retained in the
thyroid gland. A deficiency in iodine will cause the thyroid gland to work
hard and enlarge, which is called a goiter. Goiters are commonly seen in
geographical regions that have an iodine deficiency. Most table salt in
the United
States has iodine added.

77. Answer: B
Rationale: A pulse oximeter reading of less than 93% is significant. A
90% pulse oximeter reading indicates a PaO2 of approximately 60 on an
arterial blood gas; this is severe hypoxemia and requires immediate
intervention.

78. Answer: A
Rationale: . A serum sodium level of 112 mEq/L is dangerously low, and
the client is at risk for seizures. A headache is a symptom of a low
sodium level.

79. Answer: D
Rationale: The client is excreting large amounts of dilute urine. If the
client is unable to take in enough fluids, the client will quickly become
dehydrated, so tissue turgor should be assessed frequently.

80. Answer: D
Rationale: The thyroid gland (in the neck) enlarges as a result of the
increased need for thyroid hormone production; an enlarged gland is
called a goiter.

81. Answer: C
Rationale: The first action should be to determine if the client is
experiencing polyuria and
polydipsia as a result of developing diabetes insipidus, a complication of
the head trauma.

82. Answer: B
Rationale: Medication taken for DI is usually every
8–12 hours, depending on the client. The client should keep the
medication close at hand.
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83. Answer: C
Rationale: Muscle twitching is a sign of early sodium imbalance. If an
immediate intervention is not made, the client could begin to seize.

84. Answer: D
Rationale: The client with hyperthyroidism has an increased appetite;
therefore, well-balanced meals served several times throughout the day
will help with the client’s constant hunger.

85. Answer: B
Rationale: Early signs and symptoms are nausea and vomiting. The client
has a syndrome of the inappropriate secretion of the antidiuresis (against
allowing the body to urinate) hormone. In other words, the client is
producing a hormone that will not allow the client to urinate.

86. Answer: C
Rationale: Untreated hypothyroidism is characterized by an increased
susceptibility to the effects of most hypnotic and sedative agents;
therefore, the nurse would question this medication.

87. Answer: C
Rationale: This is an example of autonomy (the client has the right to
decide for himself).

88. Answer: B
Rationale: The output is more than double the intake in a short time.
This client could be developing diabetes insipidus, a complication of
trauma to the head.

89. Answer: A
Rationale: An autocratic style is one in which the person in charge makes
the decision without consulting anyone else.

90. Answer: C
Rationale: This client has a low blood pressure and tachycardia. This
client could be about to go into an Addisonian crisis, a potentially life-
threatening condition. The most experienced nurse should care for this
client.

91. Answer: B
Rationale: Iatrogenic means that a problem has been caused by a medical
treatment or procedure— in this case, treatment with steroids for another
problem. Clients taking steroids over a period of time develop the clinical
manifestations of Cushing’s disease. Disease processes for which long-term
steroids are prescribed include chronic obstructive pulmonary disease,
cancer, and arthritis.

92. Answer: D
Rationale: Fluid volume deficit (dehydration) can lead to circulatory
impairment and hyperkalemia.

93. Answer: B
Rationale: Decreased metabolism causes the client to be cold frequently;
therefore, protecting the client from exposure to cold will help increase
comfort and decrease further heat loss.
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94. Answer: A
Rationale: A decrease in the thyroid hormone causes decreased
metabolism, which leads to fatigue and hair loss.

95. Answer: A
Rationale: Radioactive iodine therapy is used to destroy the overactive
thyroid cells. After treatment the client is followed closely for 3 to 4
weeks until the euthyroid state is reached.

96. Answer: B
Rationale: The abdominal pain is often made worse by eating and lying
supine in clients diagnosed with cancer of the pancreas.

97. Answer: B
Rationale: Type 2 diabetes is a disorder that usually occurs around the
age of 40, but it is now being detected in children and young adults as
a result of obesity and sedentary lifestyles. Wounds that do not heal are
a hallmark sign of Type 2 diabetes. This client weighs 248.6 pounds and
is short.

98. Answer: C
Rationale: This potassium level is below normal, which is 3.5–5.5 mEq/L.
Therefore, the nurse would question administering this medication because
loop diuretics cause potassium loss in the urine.

99. Answer: C
Rationale: The client with hypothyroidism frequently has a subnormal
temperature, so a temperature WNL indicates the medication is effective.

100. Answer: B
Rationale: Hyperpyrexia (high fever) and heart rate above 130
beats/minute are signs of thyroid storm, a severely exaggerated
hyperthyroidism.

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