1040 Exam 3

Polyuria, polydipsia, and polyphagia

What are the hallmark signs of diabetes mellitus?

Assist the client to the floor, in a side-lying position, and protect him with linens

A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first?

Comatose

The critical care nurse is giving report on a client they are caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Exogenous insulin is required for life.

The diabetes nurse educator describes type 1 diabetes with what statement?

"Who is the president of the United States?"

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?

A normal finding; the fluid will be sent for testing to determine other factors

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate?

Parasympathetic

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste?

An absence seizure

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

nervousness, tachycardia, tremors

What assessment findings would the nurse expect to see in a client who has overdosed on levothyroxine?

It cushions the brain and spinal cord.

What is the function of cerebrospinal fluid (CSF)?

Decreased renal function

Which age-related change may affect diabetes and its management?

Oculomotor

Which cranial nerve is responsible for muscles that move the eye and lids?

The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"You will need to drink this 6-ounce bottle of orange juice."

A nurse in the school office is seeing a 7-year-old child with type 1 diabetes after gym class. The child is jittery and appears sweaty. Which intervention would the nurse advise the child to do?

A client with a recent diagnosis of type 2 diabetes who does not monitor blood sugars or control diet

Which individual likely faces the greatest risk for the development of chronic kidney disease?

Heart disease and diabetes

Which medical pair is the highest concern if reported during a pregnant client's medical history?

Anticonvulsants

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Loss of neurons in the brain

Which of the following is an age-related change in the nervous system?

Notify the health care provider.

A client with a history of cardiovascular disease, who is taking a thyroid hormone, reports chest pain. What is the nurse's best action?

Confusion

While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

Document the allergy and inform the physician

While the nurse is recording the health history of a client who is scheduled for a thyroid test, the client informs the nurse about an allergy to seafood. What is the nurse's most appropriate response?

Acoustic

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve?

sympathetic nervous system

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the:

Calcitonin

The thyroid gland produces and secretes which in direct response to serum calcium levels?

gestational diabetes

The urine of a woman in her second trimester of pregnancy is found to contain glucose. For which condition should she be tested?

"We will need to perform an assessment to determine your weight and risk status."

A client asks the nurse what needs to be done in order to begin a weight loss program. What is the nurse's best response?

TSH

A client diagnosed with hypothyroidism is to start thyroid hormone replacement therapy. Which lab value should the nurse review to assist the health care provider in determining the dosage?

body temperature cold

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

Generalized

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Encourage the client to drink liberal amounts of fluids

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?

protruding eyes and a fixed stare.

A client visits the physician's office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves' disease. Based on history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by:

Lateral recumbent, with chin resting on flexed knees

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Cerebellum

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:

Seizure was 1 minute in duration including tonic-clonic activity

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

It may trigger status epilepticus

You are taking care of a client who is taking an anticonvulsant. Why should you advise the client not to stop taking the drug abruptly?

The effects of hormonal changes during pregnancy

A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor?

"I'll have to control my blood sugars, my blood pressure, and my cholesterol in order to make sure I don't develop sight problems."

A 31-year-old female has been recently diagnosed with type 2 diabetes mellitus, and is attending a diabetes education class. Which statement by the woman demonstrates an accurate understanding of her health problem?

Insulin

A client is experiencing an increase in blood glucose levels. The nurse understands that which of the following hormones would be important in lowering the client's blood glucose level?

Assess the client for medication allergies.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

Avoid stimulants and alcohol for 24 to 48 hours before the test

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

baked turkey, brown rice, and strawberries

A nurse is caring for a pregnant client with gestational diabetes. Which meal should the nurse recommend for this client?

Exophthalmos

During the physical examination of a client with a suspected endocrine disorder, the nurse observes an abnormal bulging of the eyes. The nurse documents this finding as which of the following?

Risk for falls

In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client?

Pinpoint pupils Unequal pupils Absence of pupillary response

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

Cerebrospinal fluid is cloudy in nature.

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

increased thirst

The nurse is caring for a 10-year-old child who is newly diagnosed with type 1 diabetes mellitus. The nurse is teaching the parents how to recognize signs and symptoms of hyperglycemia. Which of the following is most important for the nurse to include as an initial symptom of hyperglycemia?

"I should take this medication on an empty stomach in the morning."

The nurse is caring for a 55-year-old client with Hashimoto's thyroiditis. During discharge teaching, which statement by the client tells the nurse the client understands the teaching?

Maintenance of a patent airway

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Iodine

With regard to the functioning of the thyroid gland, which is an essential element for the manufacturing of thyroxine and triiodothyronine?

In the lower neck, anterior to the trachea

A nurse is preparing to palpate the thyroid gland. Where would the nurse expect to find this gland?

Diabetes

According to the Centers for Disease Control (CDC, 2006), this chronic illness has tripled in occurrence since 1980:

Although the required position may not be comfortable, it will make the procedure safer and easier to perform.

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?

Turn the client to the side during a seizure and do not restrain movements

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

Weight reduction through diet and exercise

A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into her teaching plan?

Inform the client that he will not experience any electrical shock

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Positive Romberg test, indicating a problem with equilibrium

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result?

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

Cardiovascular disease

A nurse is caring for a client with excess abdominal fat. Which of the following is a risk associated with excessive abdominal fat about which the nurse should inform the client?

"I have an allergy to shrimp and shellfish."

A nurse is collecting data from a client who is suspected of having an endocrine disorder and is scheduled for diagnostic testing that involves the use of a contrast medium. The nurse would inform the physician if the client stated which of the following?

Coffee

A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test?

Calcium gluconate

After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering?

"Lately, I drink and drink and can't seem to quench my thirst."

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as being suggestive of diabetes?

Peripheral neuropathy

An older adult patient that has type 2 diabetes comes to the emergency department with second-degree burns to the bottom of both feet and states, "I didn't feel too hot but my feet must have been too close to the heater." What does the nurse understand is most likely the reason for the decrease in temperature sensation?

Polyuria

The nurse is interviewing the caregivers of a child admitted with a diagnosis of type 1 diabetes mellitus. The caregiver states, "The teacher tells us that our child has to use the restroom many more times a day than other students do." The caregiver's statement indicates the child most likely has:

CN I

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

carefully move the client to a flat surface and turn him on his side

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

stick out the tongue and move it rapidly from side to side and in and out.

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to:

beta cells of the pancreas

A nurse is explaining the action of insulin to a client with diabetes mellitus. During client teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when she states that insulin is secreted from the:

"Are you allergic to seafood or iodine?"

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?

Cerebral spinal fluid leakage at the puncture site

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following?

It is a complicated disorder that alters the metabolism of glucose.

A nurse is presenting an educational event at a local senior citizens' club about diabetes. What would the nurse tell the attendees at the event about diabetes?

CN II

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

levothyroxine

The nurse is caring for a client with hypothyroidism. The client notes, "The provider mentioned that I would need to take medication for this condition. What medication will I be prescribed?" What medication does the nurse anticipate the healthcare provider ordering?

"Diet, exercise, and weight loss can eliminate the need for medication."

A controlled type 2 diabetic client states, "The doctor said if my blood sugars remain stable, I may not need to take any medication." Which response by the nurse is most appropriate?

Risk for aspiration

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

hypoglycemia

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that the child is risk for which complication?

An 80-year-old woman who has uncharacteristically lost her appetite of late and often complains of feeling cold

Which resident of a long-term facility is exhibiting clinical manifestations of hypothyroidism?

An elevated blood glucose concentration contributes to complications of diabetes, such as diminished vision.

Which would be included in the teaching plan for a client diagnosed with diabetes mellitus?

Finger

A client with type 1 diabetes mellitus is receiving short-acting insulin to maintain control of blood glucose levels. In providing glucometer instructions, the nurse would instruct the client to use which site for most accurate findings?

Withhold anticonvulsant medications for 24 to 48 hours before the exam

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?