Question 1

The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client's risk for metabolic syndrome?

Accepted Answer

Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria include: Abdominal obesity: Waist circumference (≥40 inches [102 cm] in men, ≥35 inches [89 cm] in women) High serum triglycerides >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment Low levels of high-density lipoprotein (HDL) cholesterol (<40 mg/dL [1.0 mmol/L] in men, <50 mg/dL [1.3 mmol] in women) Hypertension ≥130/85 mm Hg or hypertension drug treatment Fasting blood glucose ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment The 55-year-old woman (waist circumference 37 inches [94 cm], triglycerides 190 mg/dL [2.2 mmol/L], fasting blood glucose 120 mg/dL [6.7 mmol/L]) is at highest risk for metabolic syndrome with 3 of 5 criteria (obesity, high triglycerides, hyperglycemia) (Option C). (Option A) The 27-year-old woman (triglycerides 210 mg/dL [2.4 mmol/L]) has only 1 metabolic syndrome-associated condition (hypertriglyceridemia). (Option B) The 45-year-old man (fasting blood glucose 118 mg/dL [6.6 mmol/L]) has only 1 metabolic syndrome-associated condition (hyperglycemia). (Option D) The 82-year-old man (blood pressure 148/88 mm Hg, fasting blood glucose 104 mg/dL [5.8 mmol/L]) has only 2 metabolic syndrome-associated conditions (hypertension, hyperglycemia). His HDL is within normal limits. Educational objective: Clients with metabolic syndrome are at increased risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria for metabolic syndrome include at least 3 of 5 conditions: abdominal obesity, hyperglycemia, low levels of high-density lipoprotein, high serum triglycerides, and hypertension.

Question 2

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider?

Accepted Answer

The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal. The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney. Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy. (Option A) Normal serum fasting blood glucose is 70-99 mg/dL (3.9-5.5 mmol/L). (Option C) Normal serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). (Option D) Normal serum sodium is 135-145 mEq/L (135-145 mmol/L). Educational objective: The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). Serum creatinine provides an estimation of the glomerular filtration rate and is an indicator of kidney function.

Question 3

The nurse teaches disease management to a group of clients with type I diabetes mellitus. Which of the following should the nurse teach as signs or symptoms associated with hypoglycemia? Select all that apply.

Accepted Answer

Hypoglycemia (low blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication that occurs when levels of insulin exceed the proportion of glucose. Epinephrine is one of the major hormones released during a hypoglycemic reaction and may cause early symptoms such as trembling, palpitations, anxiety/arousal, and restlessness. Diaphoresis and pallor are present on examination. When the brain is deprived of glucose due to prolonged and severe hypoglycemia, neuroglycopenic symptoms (confusion, seizures, coma) develop. (Option B) Flushing (red skin) is commonly seen with fever, carcinoid syndrome, polycythemia vera, and sexual intercourse. Flushing is not seen with hypoglycemia. (Option D) Polyuria and weight loss are usually associated with hyperglycemia, not hypoglycemia. Educational objective: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication. Signs and symptoms include shakiness, palpitations, anxiety/arousal, restlessness, diaphoresis, and pallor.

Question 4

The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority?

Accepted Answer

11ecbb05_c96a_25a7_b433_9f166dfa9477_MD0009_00 For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Effective chest compressions are essential for maintaining perfusion to vital organs. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest (Option C). (Option A) Interruptions in compressions should be kept to a minimum. Pulse checks are performed every 2 minutes per basic life support (BLS) guidelines or if a rhythm change is noted. (Option B) Additional large-bore IVs may be needed for emergency medication administration (eg, epinephrine, amiodarone) but can be completed when more help arrives to the client's room. (Option D) Bag valve mask breaths with 100% oxygen should be initiated after obtaining the defibrillator. Educational objective: For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest.

Question 5

A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply.

Accepted Answer

The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present. Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur. The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy. Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC0₂ in an attempt to restore the body's normal pH level and should not be reversed (Option B). (Option A) IV dextrose is administered during acute hypoglycemic episodes and would worsen DKA. Educational objective: DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin and should be treated first with rehydration (normal saline) and then insulin administration.

Question 6

When no changes are made to the diet or prescribed insulin, which client with type 1 diabetes mellitus does the nurse anticipate having the highest risk of developing hypoglycemia?

Accepted Answer

Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and sometimes life-threatening complication of diabetes mellitus. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing symptoms of hypoglycemia such as sweating, tremor, and hunger. Aerobic exercise typically lowers blood glucose levels. As muscles use up glucose, the liver is unable to produce enough glucose to keep up with the demand. Even an experienced exerciser should check blood glucose levels before, during, and after exercise, and also carry a carbohydrate drink or snack in case of a hypoglycemic episode (Option B). Clients with an acute illness (eg, influenza, cellulitis) are more likely to experience hyperglycemia. Increased glucose levels occur due to the physiological stress response caused by infection (Options A and C). Hyperglycemia is also a side effect of prednisone (Option D). Educational objective: Aerobic exercise typically lowers blood glucose levels as glucose production in the liver fails to keep up with elevated glucose uptake by the muscles at work.

Question 7

The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included?Select all that apply.

Accepted Answer

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities. Instructions for diabetic foot care include: Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand. Gently pat feet dry, particularly between the toes (Option B). Use lanolin to prevent dry and cracked skin, but do not apply between the toes. Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor. To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned (Options A, C, and D). Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option E). To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise. Report other types of problems such as infections or athlete's foot immediately. Educational objective: Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Clients should keep feet clean, dry, and free from irritation.

Question 8

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first?

Accepted Answer

11ecbb05_c96c_6f98_b433_572ed387b5f8_MD0009_00 DKA is a life-threatening complication of type I diabetes characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin. The body begins to break down fat stores into ketones, as it does in a state of starvation, causing a metabolic acidosis (low pH and low HCO₃). The lack of insulin also results in increased glucose production in the liver, worsening the hyperglycemia. Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are poor skin turgor, dry mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy. Despite laboratory values showing hyperkalemia on admission, clients with DKA have a net potassium deficiency and will need careful replacement after fluid resuscitation. (Option A) Although it is important to insert an indwelling catheter to monitor fluid balance, rehydrating the client is a life-saving measure with higher priority. (Option B) Although it is important to monitor serum potassium results before and during insulin administration, rehydrating the client is the highest priority. Dilution will also improve the hyperkalemia. (Option C) The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances. Educational objective: The severe hyperglycemia of diabetic ketoacidosis (DM1) and hyperosmolar hyperglycemic state (DM2) causes severe dehydration from an osmotic diuresis. IV normal saline resuscitation should be started before any other therapy

Question 9

The nurse teaches proper foot care to a client with diabetes mellitus. Which statement by the client indicates that further teaching is needed?

Accepted Answer

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury. Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care: Proper footwear - Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks. Daily hygiene and inspection - Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes) (Option A). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes. Injury avoidance - Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options C and D). Report problems - Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately. Educational objective: Careful, daily attention to foot care can prevent long-term complications. Clients with diabetes should be taught to wear closed-toed, leather-based shoes to prevent injury. Clients should also receive instruction regarding daily hygiene and inspection, injury avoidance, and prompt reporting of problems.

Question 10

During a screening clinic, the nurse performs a health assessment on several adult clients. Which finding by the nurse is most important to report to the primary health care provider?

Accepted Answer

11ecbb05_c970_402a_b433_e3da8b2d4523_MD0009_00 Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans. Both indicate insulin resistance (diabetic dermopathy). The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome. (Option A) A BMI of 18.5 to 24.9 kg/m² indicates a normal weight. (Option C) A fasting total cholesterol <200 mg/dL (5.2 mmol/L) is normal. (Option D) Although any change or growth of a mole should be reported, a pale or brown round mole <5 mm is typically a normal finding. Educational objective: Acanthosis nigricans is a velvety light brownish to black skin thickening seen in the axillae, neck, or flexures and is indicative of insulin resistance (diabetic dermopathy). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans.

Question 11

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

Accepted Answer

Diabetic neuropathy is caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus. Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly. (Options A, B & C) Sensory or peripheral neuropathy affects the peripheral nervous system and may cause problems with the extremities. Educational objective: Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension and put the client at risk for falls.

Question 12

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

Accepted Answer

11ecbb05_c969_6256_b433_b99be3a336c3_MD0009_00 The basic life support sequence is compressions, airway, and breathing (mnemonic - CAB). High-quality CPR is associated with improved client outcomes and begins with high-quality chest compressions (ie, 100-120/min, 2-2.4 in [5-6 cm] deep). Any unwitnessed collapse should be treated with 2 minutes of CPR, followed by activating the emergency response system and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume high-quality chest compressions immediately (Option C). (Option A) Chest compressions should not be interrupted for more than 10 seconds when assessing for a pulse and chest rise/fall. (Option B) Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to clients who have a pulse but are not breathing normally. For clients with no pulse, the nurse should deliver cycles of 30 compressions followed by 2 rescue breaths. (Option D) The jaw-thrust maneuver is used instead of the head-tilt/chin-lift method in clients who may have a head/spinal injury. Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing. Assessing the airway is not indicated at this time. Educational objective: In basic life support for an unresponsive, pulseless client, the nurse should begin with 2 minutes of CPR in cycles of 30 high-quality chest compressions to 2 rescue breaths, followed by activating the emergency response system and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume chest compressions immediately.

Question 13

A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit.  The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse.  Which action by the nurse is appropriate?

Accepted Answer

An implantable cardioverter defibrillator (ICD) is a medical device that is surgically implanted underneath the skin that can sense life-threatening arrhythmia and discharge electrical shocks directly into the cardiac muscle to correct the arrhythmia. Clients typically receive ICDs after a history of sustained or recurrent ventricular tachycardia (VT), including personal or family history of sudden cardiac death and severe heart failure. When caring for a client with an ICD, it is critical that the nurse monitor for ICD firings (eg, client report, observation on cardiac monitors). After firings, the nurse should monitor for resolution of the arrythmia, indications of hemodynamic compromise (eg, hypotension, chest pain, altered mentation), and additional ICD discharges. Occasionally, an ICD may be unable to convert the arrythmia to a hemodynamically stable rhythm and will repeatedly shock the client. If the client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should promptly obtain a manual external defibrillator and initiate measures to prevent hemodynamic instability and cardiac arrest (Option D). (Option A) Stimulating a vagal response (eg, coughing) is an appropriate intervention for supraventricular tachycardia. (Options B and C) Deactivating the ICD and obtaining an ECG are not appropriate at this time because they delay lifesaving interventions. Educational objective: An implantable cardioverter defibrillator (ICD) is a device used to sense life-threatening arrhythmia and discharge electrical shocks to correct the arrhythmia. If a client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should obtain a manual external defibrillator and initiate cardiac life support.

Question 14

A client is admitted to the intensive care unit with diagnoses of a brain tumor complicated by transient diabetes insipidus. Which client data related to this complication should the nurse expect? Select all that apply.

Accepted Answer

Diabetes insipidus (DI) is a condition in which antidiuretic hormone (ADH) is insufficiently produced or suppressed. Neurogenic DI results from manipulation or interference with ADH release, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. It is characterized by polydipsia (increased thirst) and polyuria (increased urine output) and can lead to dehydration resulting in weight loss (Option D), hypernatremia, and a high serum osmolality (>295 mOsm/kg [295 mmol/kg]). Urine is dilute and copious (2-20 L/day) (Option A) with a low specific gravity (<1.003). Educational objective: Diabetes insipidus is a condition in which antidiuretic hormone is insufficiently produced or suppressed, resulting in polydipsia and polyuria (up to 20 L/day). Urine is copious and dilute with a low specific gravity (<1.003). Fluid volume deficit can lead to dehydration, hypernatremia, high serum osmolality, and weight loss.

Question 15

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results?

Accepted Answer

Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes. The A1C test measures blood glucose control over a period of 2-3 months; higher measurements indicate higher glycemic levels. High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic medication regimen. It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C. (Option A) Although it is important to review signs and symptoms of hypoglycemia with all clients with diabetes, this statement does not address the elevated hemoglobin A1C. (Option C) A diet recall of the last 24-48 hours will not give the nurse adequate information on possible causes of an elevated hemoglobin A1C as this test measures glycemic control over 2-3 months. (Option D) A hemoglobin A1C may be tested when the client is not fasting. Educational objective: Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood over a period of 2-3 months. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes.

Question 16

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

Accepted Answer

11ecbb05_c968_ed25_b433_7123ea856f58_MD0009_00 Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Cardiac tamponade decreases atrioventricular filling and impairs the heart's ability to contract and eject blood; it is life-threatening without prompt recognition and treatment. Clinical features of cardiac tamponade include hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) (Option C). In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, and tachycardia may be present. (Option A) Palpitations, tachycardia, and irregular pulse are expected findings in atrial fibrillation. Atrial fibrillation is usually a chronic arrhythmia. The heart rate must be controlled, but this is not a priority over tamponade. (Option B) Liver cirrhosis causes portal hypertension and splenomegaly. An enlarged spleen sequestrates platelets, causing thrombocytopenia. Spontaneous bleeding requires further investigation after addressing a client with possible cardiac tamponade. (Option D) Increased white blood cell count in a client with infection may indicate ineffective treatment and/or progression to sepsis, both of which require follow-up. However, this finding is not immediately life-threatening. Educational objective: Cardiac tamponade is a possible complication of acute pericarditis that impairs cardiac output and is life-threatening without immediate intervention. Clinical features of cardiac tamponade include hypotension, muffled heart sounds, and neck vein distension (Beck triad).

Question 17

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy.  Which intervention should the nurse implement?

Accepted Answer

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option C). ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). (Option B) DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria). (Option D) The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions. Educational objective: DI occurs when there is insufficient production/suppression of ADH. It is characterized by polydipsia and polyuria with diluted urine. Oral and/or intravenous fluid replacement is imperative to prevent dehydration. DI is treated with ADH replacement drugs (eg, desmopressin acetate [DDAVP]). Clients should be monitored for urine output, urine specific gravity, and serum sodium.

Question 18

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease. Which nursing action(s) should be included in the client's plan of care? Select all that apply.

Accepted Answer

11ecbb05_c971_c6cb_b433_357ec7ee5ffb_MD0009_00 Exophthalmos is a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone overproduction) from Graves' disease. It is defined as a protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection. Nursing care for a client with exophthalmos includes: Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area Using artificial tears or other similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers) Taping the client's eyelids shut during sleep if they do not close on their own Teaching the client the following: Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition.If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos.Smoking cessation is necessary as smoking increases the risk of Graves' disease and associated eye problems.Restrict salt intake to decrease periorbital edema.Use dark glasses to decrease glare and prevent external irritants and infection.Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility. Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition. If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos. Smoking cessation is necessary as smoking increases the risk of Graves' disease and associated eye problems. Restrict salt intake to decrease periorbital edema. Use dark glasses to decrease glare and prevent external irritants and infection. Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility. Educational objective: Exophthalmos is a complication of hyperthyroidism from Graves' disease leading to increased orbital tissue (connective, adipose, muscular) expansion that can be irreversible. Nursing care to keep eyes moist and protected is needed to prevent corneal ulcers and infection.

Question 19

The nurse is caring for a client who, 30 minutes ago, underwent an ablation procedure for supraventricular tachycardia in the cardiac catheterization laboratory.  The client has a dressing over the femoral insertion site with a small amount of oozing blood.  Which action by the nurse causes the charge nurse to intervene?

Accepted Answer

Radiofrequency catheter ablation is an invasive procedure that may be used to treat clients with recurrent episodes of supraventricular tachycardia. A catheter is inserted through a large artery or vein (eg, femoral) and threaded to the heart. Radiofrequency waves are delivered to inactivate tissue in the area of the heart causing the dysrhythmia. After cardiac catheterization, clients must remain supine with the head of the bed at ≤30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site. The charge nurse should intervene if the nurse is assisting the client to sit on the side of the bed to use the urinal (Option C). (Option A) A small amount of bleeding can be expected after the catheter is removed. It is appropriate to apply pressure above the insertion site to control bleeding. The nurse should continue to closely monitor the site for further bleeding. (Option B) It is important to verify adequate perfusion to the affected limb by frequently palpating the pedal pulses. Bilateral pulses should be palpated for comparison. (Option D) Chest pain after ablation may be due to cardiac muscle damage but could also be caused by cardiac ischemia. This should be reported immediately to the health care provider. Educational objective: Radiofrequency catheter ablation is a cardiac catheterization procedure indicated for a client with recurrent episodes of supraventricular tachycardia. After cardiac catheterization, the client must remain supine with the head of the bed at ≤30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site.

Question 20

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply.

Accepted Answer

11ecbb05_c96f_f209_b433_c7e8ffc1f6ea_MD0009_00 Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options A and D). Educational objective: Hyperosmolar hyperglycemic state differs from diabetic ketoacidosis in that it is typically associated with type 2 diabetes mellitus. Because these clients produce some insulin, severe hyperglycemia happens more slowly and is often not noted until neurological manifestations occur.

Exam 1: Adult Health

The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client's risk for metabolic syndrome?

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider?

The nurse teaches disease management to a group of clients with type I diabetes mellitus. Which of the following should the nurse teach as signs or symptoms associated with hypoglycemia? Select all that apply.

When no changes are made to the diet or prescribed insulin, which client with type 1 diabetes mellitus does the nurse anticipate having the highest risk of developing hypoglycemia?

The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included?Select all that apply.

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA) . After checking the blood glucose, which prescription should the nurse implement first?

The nurse teaches proper foot care to a client with diabetes mellitus. Which statement by the client indicates that further teaching is needed?

During a screening clinic, the nurse performs a health assessment on several adult clients. Which finding by the nurse is most important to report to the primary health care provider?

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

A client is admitted to the intensive care unit with diagnoses of a brain tumor complicated by transient diabetes insipidus. Which client data related to this complication should the nurse expect? Select all that apply.

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results?

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy. Which intervention should the nurse implement?

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease. Which nursing action(s) should be included in the client's plan of care? Select all that apply.

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply.