Question 1

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time?

Accepted Answer

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management. Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option A). (Option B) When the supply of insulin is insufficient and glucose cannot be metabolized for energy, the body breaks down fat stores leading to ketosis (fruity breath) and metabolic acidosis. However, it does not pose the greatest risk to survival and is not the priority ND. (Option C) Tachypnea and deep labored respirations (ie, Kussmaul) are the body's attempt to eliminate excess acid (pCO₂) through hyperventilation and normalize the pH. However, it does not pose the greatest risk to survival and is not the priority ND. (Option D) Ineffective health maintenance related to inability to manage a condition during illness (evidenced by DKA development in this client) is an appropriate ND. However, it does not pose the greatest risk to survival at this time and is not the priority ND. Educational objective: Hyperglycemia associated with DKA leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Deficient fluid volume related to osmotic diuresis is an appropriate ND for a client with DKA.

Question 2

A client's diabetes is controlled with a morning dose of glargine and a scheduled, fixed dose of lispro with meals.  Before breakfast, the client's fingerstick glucose is 105 mg/dL (5.8 mmol/L).  The tray is in the room, and the client is eager to eat.  What action should the nurse take?

Accepted Answer

11ecbb05_c981_0911_b433_8b62287ebfcc_MD0009_00 Glargine (Lantus) is a long-acting (basal) insulin given to prevent hyperglycemia for 24 hours. The drug has no peak, and so timing of administration is not dependent on food intake. However, if the client is NPO for more than 12 hours, the provider may hold it. Lispro (Humalog) is a rapid-acting insulin with a peak of 30 minutes to 3 hours and should be given only if it is certain the client will eat within 15 minutes. Lispro is prescribed in two ways: Scheduled prandial (ie, fixed dosage) given to prevent hyperglycemia with consumption of food. Typically, this would not be held unless the blood sugar is below normal (70 mg/dL [3.9 mmol/L]) or according to facility guidelines. Correctional (ie, sliding-scale dosage) given to correct hyperglycemia. Typically, this would be held when blood glucose is below 150 mg/dL (8.3 mmol/L). Both glargine and lispro would be given according to schedule, as the client is not NPO and plans to eat immediately, and glucose is above 70 mg/dL [3.9 mmol/L] (Option A). (Options B, C, and D) Holding glargine will increase the blood sugar level over 24 hours. Holding lispro will cause blood glucose to rise uncontrollably due to the consumption of food. Educational objective: Rapid-acting insulin (eg, scheduled prandial fixed dosing, correctional sliding-scale dosing) is given if a client plans to eat within 15 minutes. Scheduled prandial insulin prevents hyperglycemia after meals and is held when blood glucose is below normal (70 mg/dL [3.9 mmol/L]). Correctional insulin corrects existing hyperglycemia.

Question 3

The nurse receives report on 4 clients. Which client should the nurse assess first?

Accepted Answer

Thyrotoxicosis (ie, thyroid storm) is a life-threatening condition characterized by an increase in thyroid hormone levels that results in a hypermetabolic state. Most commonly, thyrotoxicosis occurs as an exacerbation of hyperthyroidism, an overactive thyroid disorder, and is treated with antithyroid medications and/or surgical removal of the thyroid (ie, thyroidectomy). However, thyrotoxicosis may also occur due to excess thyroid hormone intake from medications and physical manipulation of the thyroid gland. The nurse caring for a client after thyroidectomy must closely monitor for and immediately report any clinical manifestations of thyrotoxicosis (eg, fever, anxiety, tachycardia), particularly in clients with hyperthyroidism (Option A). After surgery, thyroid hormone levels can remain elevated for several days, and may even increase, from intraoperative thyroid gland manipulation. Without treatment, thyrotoxicosis can rapidly progress to lethal complications (eg, hyperthermia, malignant hypertension, ventricular tachycardia). (Options B and C) Clients reporting pain or discomfort require further assessment and intervention after addressing the client with potentially life-threatening complications. (Option D) Headache is a common adverse effect of nitrate medications that usually resolves without intervention. Educational objective: Thyrotoxicosis is a life-threatening, hypermetabolic condition caused by elevated thyroid hormone levels that is treated with antithyroid medications and/or surgical thyroid gland removal (ie, thyroidectomy). The nurses providing postoperative thyroidectomy care must monitor for and report clinical manifestations of thyrotoxicosis (eg, chills, fever) because thyroid hormones may remain elevated, or increase, for several days postoperatively.

Question 4

The nurse is planning care for a client immediately following a thyroidectomy. Which of the following nursing actions are appropriate to include in the plan of care? Select all that apply.

Accepted Answer

Thyroidectomy is a surgery involving partial or complete removal of the thyroid, often to treat hyperthyroidism or thyroid cancer. Clients undergoing a thyroidectomy require close monitoring as they are at increased risk for airway compromise due to potential neck swelling, hypocalcemia, and nerve damage. Nurses planning care following a thyroidectomy promote client recovery and monitor for and prevent complications by: Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling, stridor, Trousseau and Chvostek signs), which may occur from parathyroid gland trauma during surgery (Option A) Assessing for stridor and new or worsening changes in voice strength and quality (eg, hoarseness, whispering), which may indicate laryngeal nerve damage that can result in respiratory arrest (Option E) Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) at the bedside in case respiratory distress develops (Option C) Maintaining the client in semi-Fowler position, which promotes drainage of surgical site edema around the neck and reduces the risk of respiratory distress (Option D) (Option B) Postoperatively, the client should avoid excessive neck flexion and extension, which may strain and cause disruption of the incision site, leading to hemorrhage. Encourage the client to maintain neutral head and neck alignment. Educational objective: Following a thyroidectomy, place the client in semi-Fowler position with a neutral head and neck position. Keep a tracheostomy kit, suction, and oxygen at the bedside in case airway compromise develops. Monitor frequently for signs of hypocalcemia and changes in voice strength and quality.

Question 5

The nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first?

Accepted Answer

Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). (Option A) The post-thyroidectomy client who needs a refill of the thyroid replacement medication should be contacted third. Without thyroid replacement therapy, this client would experience signs and symptoms of hypothyroidism (eg, extreme fatigue, bradycardia). (Option B) Clients on corticosteroids may report moods swings and irritability; these are common side effects. (Option C) The client with diabetes who is asymptomatic but has elevated blood sugars should be contacted second as prolonged hyperglycemia may lead to dehydration and acidosis. Educational objective: Clients with hyperthyroidism are at risk for developing thyroid storm, a life-threatening condition. Symptoms include fever, tachycardia, cardiac dysrhythmias, nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise.

Question 6

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

Accepted Answer

11ecbb05_c98f_60f5_b433_f1d67f21dfa6_MD0009_00 Postoperative nursing care after a laparoscopic cholecystectomy focuses on prevention of complications. Carbon dioxide (CO₂) is used to inflate and expand the abdominal cavity during laparoscopic procedures to allow insertion of surgical instruments and better visualization of the abdominal organs. CO₂ can irritate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the right shoulder. referred pain The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO₂ used during surgery (Option B). Early ambulation not only improves breathing but also decreases the risk of thromboembolism and stimulates peristalsis. (Option A) Anti-embolism stockings help prevent the development of deep vein thrombosis, but early ambulation is more effective at thromboembolism prevention and is therefore the priority intervention. (Option C) Stool softeners may prevent postoperative constipation caused by surgical anesthetics and opioids, which contribute to decreased peristalsis. However, early ambulation promotes bowel motility and reduces constipation. (Option D) After laparoscopic cholecystectomy, the client should maintain a clear liquid diet until bowel sounds return. After obtaining an order from the health care provider, the nurse should advance to a low-fat diet and educate the client on weight reduction and maintaining a low-fat diet. Educational objective: The priority of care after a laparoscopic cholecystectomy is the prevention of complications. Early ambulation helps prevent complications by: improving breathing and reducing discomfort from the carbon dioxide used to expand the abdomen during surgery; decreasing the risk of thromboembolism; and stimulating peristalsis/bowel motility.

Question 7

The nurse is caring for a client recovering from a thyroidectomy to treat hyperthyroidism. Which assessment finding would require the nurse to immediately notify the health care provider?

Accepted Answer

Thyrotoxicosis (ie, thyroid storm) is a life-threatening condition characterized by an increase in thyroid hormone levels that results in a hypermetabolic state. Most commonly, thyrotoxicosis occurs as an exacerbation of hyperthyroidism and is treated with antithyroid medications and/or surgical removal of the thyroid (thyroidectomy). However, thyrotoxicosis may also occur due to excess thyroid hormone intake from medications and physical manipulation of the thyroid gland. The nurse caring for a client after thyroidectomy must closely monitor for and immediately report any clinical manifestations of thyrotoxicosis (eg, fever, chills, tachycardia), including small rises in body temperature (Option D). After surgery, thyroid hormone levels can remain elevated for several days and may even increase from intraoperative thyroid gland manipulation. Without treatment, thyrotoxicosis can rapidly progress to lethal complications (eg, hyperthermia, ventricular tachycardia). (Options A and C) Expected postsurgical findings (eg, pain, small volume incisional bleeding) do not require notification unless the findings are unresolved by interventions (eg, pain medicine) or excessive (eg, continuous or large volume bleeding). (Option B) Postoperative sore throat is expected due to irritation from the endotracheal tube used during surgery. However, the nurse should monitor for hoarseness or noisy breathing, which may indicate laryngeal stridor and airway compromise. Educational objective: Thyrotoxicosis is a life-threatening, hypermetabolic condition caused by elevated thyroid hormone levels that is treated with antithyroid medications and/or surgery. The nurse providing postoperative thyroidectomy care must monitor for and report clinical manifestations of thyrotoxicosis (eg, chills, fever) because thyroid hormones many remain elevated, or increase, for several days postoperatively.

Question 8

The nurse is caring for a client with suspected Graves disease. Which assessment finding requires priority intervention?

Accepted Answer

Thyroid storm is a serious and potentially life-threatening emergency for clients with Graves disease. This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection). Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-41 C). Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures. (Option B) Heat intolerance is an expected symptom in hyperthyroidism, including Graves disease. (Option C) Tachycardia and arrhythmias (eg, atrial fibrillation) are commonly seen with hyperthyroidism of any cause, including Graves disease. These alone cannot differentiate whether the client has simple hyperthyroidism or life-threatening thyroid storm. (Option D) Exophthalmos (protruding eyeball) is commonly seen in Graves disease. The eyelids do not close over the eyeballs properly, leading to excessive dryness and resultant corneal damage (exposure keratitis). Although it is important to treat exophthalmos, it is not immediately life-threatening. Educational objective: Thyroid storm is a life-threatening complication of Graves disease. Fever, altered mentation, and excess autonomic activity (eg, severe hypertension, tachycardia) are common. Early recognition and treatment are crucial.

Question 9

The nurse cares for a client with type 1 diabetes mellitus who is obtunded and responding to only painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L). Which initial action by the nurse is best?

Accepted Answer

Hypoglycemia, a potentially life-threatening complication of diabetes mellitus, is identified by blood glucose <70 mg/dL (<3.9 mmol/L) and often occurs as a result of illness or inappropriate use of antidiabetic medications. When blood glucose levels (BGLs) are low, the body activates the autonomic nervous system, causing shakiness, palpitations, and sweating. Without intervention, hypoglycemia may cause altered mental status (eg, difficulty speaking, confusion), which may progress to seizures, coma, and death. Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer IV glucose replacement (eg, 50% dextrose in water) to quickly restore BGLs and prevent potentially lethal neurological changes (Option A). Afterward, the nurse should retest the BGL every 15 minutes, repeating treatment if it remains low. (Option B) Clients with altered mental status (eg, obtunded, responsive only to painful stimuli) are at high risk for aspiration and are not appropriate candidates for oral glucose replacement. (Options C and D) Obtundation, a sign of severe hypoglycemia, and a confirmed BGL of 38 mg/dL (2.11 mmol/L) are sufficient indicators for implementing emergency intervention. Assessment of additional signs of hypoglycemia, heart rate, and blood pressure should not delay implementation of lifesaving treatment. Educational objective: Hypoglycemia is a complication of diabetes mellitus that can lead to coma, seizures, and death without prompt intervention. Nurses caring for clients with hypoglycemia and altered mental status should administer IV glucose to quickly restore blood glucose levels. Lifesaving treatment should not be delayed to perform further assessments.

Question 10

The nurse is assessing a group of clients in the community health clinic for metabolic syndrome. Which clients exhibit features of the syndrome? Select all that apply.

Accepted Answer

Individuals with metabolic syndrome (insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome. Metabolic syndrome is characterized by the presence of 3 or more of the following criteria: Increased waist circumference: ≥40 in (102 cm) in men, ≥35 in (89 cm) in women (Option B) Blood pressure: ≥130 mm Hg systolic or ≥85 mm Hg diastolic or drug treatment for hypertension (Option C) Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides (Option E) High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C Fasting glucose levels: ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose (Option D) The mnemonic for metabolic syndrome is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose). (Option A) The normal LDL level is <100 mg/dL (2.6 mmol/L); therefore, this client's LDL level is within normal limits. LDL level is not a criterion for diagnosing metabolic syndrome, although a normal level is important for cardiovascular health. Educational objective: Features of metabolic syndrome include increased waist circumference, elevated blood pressure, increased triglycerides, decreased HDL, and increased fasting blood glucose. The mnemonic is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose).

Question 11

The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance?

Accepted Answer

11ecbb05_c98e_2874_b433_9f1f428dee73_MD0009_00 The nurse would expect a client experiencing an upper gastrointestinal (GI) bleed to have black tarry stools (melena). As blood passes through the GI tract, digestion of the blood ensues, producing the black tarry appearance. (Option B) Bright red bloody stool (hematochezia) would indicate a lower GI hemorrhage. (Option C) Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay-colored" stool. (Option D) Small, dry, rocky-hard masses are an indication of constipation. Inactivity, slow peristalsis, low intake of fiber in the diet, decreased fluid intake, and some medications (eg, anticholinergics) may contribute to constipation. Educational objective: Clients with upper gastrointestinal (GI) bleed tend to have black tarry stools (melena). Lower GI bleeding will have bright red bloody stool. Blood present on surface of stool indicates hemorrhoids.

Question 12

A client with type 1 diabetes mellitus is on intensive insulin therapy. The client is of the Islamic faith and insists on fasting during Ramadan. What is the most important nursing action?

Accepted Answer

Diabetic clients whose religious practices require them to change their current diet (eg, fasting) and glycemic management regimen should be assessed for clinical stability (eg, comorbidities) and glycemic control, including: History of hyperglycemia, hypoglycemia, and ketoacidosis Dosage and timing of medications Knowledge of meal planning Ability to perform blood glucose monitoring during the fast Fasting during Ramadan is one of the Five Pillars of Islam. Observance of Ramadan and daytime fasting occurs throughout the ninth month of the lunar calendar. During this time, Muslim clients are required to refrain from food and drink from dawn to sunset. Clients who are sick, children, pregnant women, and the elderly are exempt from fasting; however, some clients who fall into these categories may insist on fasting, creating challenges for their health care team. (Option A) Clients with diabetes who are at lower risk for adverse events while fasting based on risk assessment need to receive instruction on adjusting their meal planning, physical exercise, and insulin therapy. Those at high risk for complications should be discouraged from fasting. (Options C and D) These are appropriate nursing actions after the client has been assessed for risk of diabetic complications from fasting. Educational objective: Clients with diabetes who insist on fasting for religious reasons need to be assessed for risk of adverse events. Key assessment areas include clinical stability and glycemic control (eg, history of hyper-/hypoglycemic episodes, medication regimen, and the ability to self-monitor blood glucose during the fast).

Question 13

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning?

Accepted Answer

Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain may indicate abscess formation (Option D). The abscess must be treated promptly to prevent sepsis. The health care provider should be notified immediately as antibiotic therapy and immediate surgical management may be required. (Option A) Elevated blood glucose is an expected finding in clients with pancreatitis. Elevated blood glucose is associated with pancreatic dysfunction and may necessitate insulin administration, but this is not the most concerning finding. (Option B) Clients with acute pancreatitis often report severe, burning midepigastric abdominal pain that radiates to the back. Clients may seek relief from pain by positioning themselves in the knee-chest position, which decreases intra-abdominal pressure. Pain relief interventions should be attempted, but this is not the priority. (Option C) The client with pancreatitis may develop steatorrhea (eg, fatty, yellow, foul-smelling stools) due to a decrease in lipase production. Although fluid and nutritional status are important, this does not take precedence over a possible surgical emergency. Educational objective: Acute pancreatitis may cause severe midepigastric abdominal pain, elevated blood glucose levels, and steatorrhea. The nurse should watch closely for high fever, increasing abdominal pain, and leukocytosis as these findings may indicate infection of the necrosed pancreas or pancreatic abscess formation.

Question 14

The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply.

Accepted Answer

11ecbb05_c984_1652_b433_2fe16c5388db_MD0009_00 Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating. (Options C, E, and F) Fever, tachycardia, and sweating are signs of hyperthyroidism, which is a hypermetabolic state, with signs and symptoms that are usually the opposite of those seen in hypothyroidism. The presenting symptoms of a hyperthyroid client would likely include weight loss despite an increased appetite and difficulty sleeping. Educational objective: Hypothyroidism is associated with symptoms of a low metabolic rate; hyperthyroidism causes symptoms of a high metabolic rate.

Question 15

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy. What will the nurse emphasize as most important to report immediately?

Accepted Answer

Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated. (Option A) Although elevated blood pressure is important to monitor, it is a less serious symptom than stridor. (Option B) An irregular heart rate is a less serious symptom than stridor, and it may be a baseline finding in the client with hyperthyroidism. (Option C) Although low oxygen saturation is a sign of impending airway compromise, it is also commonly seen in all types of postoperative clients, making it a less specific sign of airway obstruction than noisy breathing in the thyroidectomy client. Educational objective: Airway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention.

Question 16

A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? Select all that apply.

Accepted Answer

A client recovering from abdominal surgery first consumes ice chips after demonstrating adequate bowel function (return of bowel sounds and passing flatus). After ice chips, postoperative diet progression continues to clear liquids, full liquids, soft diet, and then regular diet. postoperative diet progression Unsweetened tea, chicken broth, and apple juice are appropriate food choices for a client on a clear liquid diet (Options A, C, and E). (Option B) Popsicles are part of a clear liquid diet. However, red dyes in clear liquids (eg, cherry popsicles, red gelatin) should not be given to clients with recent gastrointestinal bleeding. If a client vomits, the vomitus may appear red and falsely lead the nurse to believe that the client is bleeding. It is important to implement prudent nursing judgment and fully consider the client's condition when making care decisions; for this client, a green or yellow popsicle would be more appropriate. (Options D and F) Frozen yogurt and vanilla ice cream are appropriate food choices for a client on a full liquid diet. Educational objective: A postoperative diet begins with ice chips and progresses to clear liquids, full liquids, soft diet, and then regular diet. Clear liquids with red dyes should not be given to clients with recent gastrointestinal bleeding.

Question 17

The nurse reviews prescriptions for assigned adult clients.  Which prescription should the nurse question?

Accepted Answer

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is associated with increased water reabsorption and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional hyponatremia. In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45% NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance. A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia. (Option B) Isotonic fluids (eg, normal saline) are appropriate for clients with volume deficit such as those with gastrointestinal bleeding. (Option C) Septic shock involves an inflammatory response to pathogens that leads to massive vasodilation and increased capillary permeability, resulting in intravascular hypovolemia and severe hypotension. An isotonic solution (eg, 0.9% NaCl) bolus is prescribed to expand intravascular volume and increase blood pressure. (Option D) A burn injury causes tissue damage and increased capillary permeability; this leads to fluid and electrolyte losses related to evaporation and intravascular fluid shifts into the interstitial tissue, which result in hypovolemia, hemoconcentration (eg, hematocrit >53% [0.53]), and hypotension. An isotonic solution (eg, lactated Ringer's) is prescribed to replace fluid and electrolyte losses. Educational objective: Syndrome of inappropriate antidiuretic hormone secretion is associated with hypervolemia and dilutional hyponatremia. Fluid restriction and hypertonic IV solutions (eg, 3% saline) are prescribed to correct hyponatremia.

Question 18

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner.  Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week.  Which action is appropriate for the nurse to recommend to the client?

Accepted Answer

11ecbb05_c987_4aa3_b433_892b9c24c747_MD0009_00 NPH insulin is intermediate-acting with an onset of 1-2 hours, peak of 4-12 hours, and duration of 12-18 hours. Due to its long peak, hypoglycemia (blood glucose <70 mg/dL [<3.9 mmol/L]) can result from use of NPH, especially because the overnight hours (during sleep) typically represent the longest interval between meals. To prevent hypoglycemia related to an evening dose of NPH, the client should eat a bedtime snack consisting of protein and complex carbohydrates (eg, cereal with milk, crackers with peanut butter) (Option B). Complex carbohydrates paired with protein provide sustained, slow release of glucose, thereby preventing hypoglycemia. (Option A) Testing for urine ketones should be done as part of a sick-day plan or when evaluating for diabetic ketoacidosis. Ketosis occurs in hyperglycemia, especially when blood glucose is >180 mg/dL (>10 mmol/L). (Option C) Increasing the client's carbohydrate intake at each meal may disrupt glycemic control and lead to a persistent elevation of blood glucose. Elevated blood glucose can cause complications, such as diabetic ketoacidosis. (Option D) The client may require an adjustment to the prescribed insulin regimen; however, it is dangerous for the client to drastically alter the prescribed dose. In addition, it is outside the nurse's scope of practice to recommend a change in the prescribed dose. Educational objective: NPH insulin is an intermediate-acting insulin that peaks in 4-12 hours. In asymptomatic clients, the best intervention to prevent low blood glucose levels related to an evening dose of NPH is to consume a bedtime snack of protein and complex carbohydrates.

Question 19

Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply.

Accepted Answer

11ecbb05_c990_7266_b433_b335e7790a0b_MD0009_00 Client teaching related to peptic ulcer disease (PUD) includes lifestyle changes (eg, dietary modifications, stress reduction), PUD complications, and medication administration. Helicobacter pylori infection and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors for complicated PUD. H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin). (Option E) Clients with PUD should avoid NSAIDs [eg, aspirin, ibuprofen (Motrin)] as they inhibit prostaglandin synthesis, increase gastric secretion, and reduce the integrity of the mucosal barrier. Educational objective: Clients with peptic ulcer disease should avoid NSAIDs, smoking, and excess use of alcohol or caffeine.

Question 20

The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply.

Accepted Answer

Addison's disease, or chronic adrenal insufficiency, occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens). Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback. Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids (Options C and E). (Option A) Acanthosis nigricans is a skin condition that occurs with obesity and diabetes and appears as velvet-like patches of darkened, thick skin. These areas typically occur around the back of the neck and in the groin and armpits. (Option B) Hirsutism is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing's syndrome. Loss of libido and decreased axillary and pubic hair are common in Addison's disease due to lower levels of androgens. (Option D) Clients with Cushing's syndrome, an overproduction of steroid hormones, have truncal obesity or large deposits of abdominal fat. Educational objective: Addison's disease (chronic adrenal insufficiency) leads to hyperpigmented skin, low blood pressure, weight loss, and muscle weakness.

Exam 1: Adult Health

A client's diabetes is controlled with a morning dose of glargine and a scheduled, fixed dose of lispro with meals. Before breakfast, the client's fingerstick glucose is 105 mg/dL (5.8 mmol/L) . The tray is in the room, and the client is eager to eat. What action should the nurse take?

The nurse receives report on 4 clients. Which client should the nurse assess first?

The nurse is planning care for a client immediately following a thyroidectomy. Which of the following nursing actions are appropriate to include in the plan of care? Select all that apply.

The nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first?

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

The nurse is caring for a client recovering from a thyroidectomy to treat hyperthyroidism. Which assessment finding would require the nurse to immediately notify the health care provider?

The nurse is caring for a client with suspected Graves disease. Which assessment finding requires priority intervention?

The nurse cares for a client with type 1 diabetes mellitus who is obtunded and responding to only painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L) . Which initial action by the nurse is best?

The nurse is assessing a group of clients in the community health clinic for metabolic syndrome. Which clients exhibit features of the syndrome? Select all that apply.

The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance?

A client with type 1 diabetes mellitus is on intensive insulin therapy. The client is of the Islamic faith and insists on fasting during Ramadan. What is the most important nursing action?

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning?

The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply.

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy. What will the nurse emphasize as most important to report immediately?

A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? Select all that apply.

The nurse reviews prescriptions for assigned adult clients. Which prescription should the nurse question?

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week. Which action is appropriate for the nurse to recommend to the client?

Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply.

The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply.