Exam 1
Which is a complication of hyperthyroidism? A. myxedema coma B. Hypothyroidism C. addisonian crisis D. acromegaly
Hypothyroidism
A patient has been taking tricyclic antidepressants for many years for the treatment of depression. The patient has developed SIADH and has been admitted to the acute care facility. What should the nurse carefully monitor when caring for this patient? (Select all that Apply) A. strict intake and output B. neurological status C. daily weights D. liver function tests E. signs of dehydration
A. strict intake and output B. neurological status C. daily weights
The nurse is performing a shift assessment of a client with aldosteronism. What assessments should the nurse include? (Select all that apply) A. urine output B. blood pressure C. peripheral pulses D. skin integrity E. signs of symptoms of venous thromboembolism F. potassium level
A. urine output B. blood pressure F. potassium level
Which hormonal deficiency causes diabetes insipidus in a client? A. Prolactin B. Thyrotropin C. Luteinizing hormone D. Antidiuretic hormone (ADH)
Antidiuretic hormone (ADH)
Which finding in a client who has syndrome of inappropriate antidiuretic hormone (SIADH) is an expected finding? A. Preservation of salt B. Retention of water C. Decrease of vasopressin D. Presence of pedal edema
Retention of water
A nurse is caring for a client with diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse anticipate? A. decreased specific gravity B. presence of ketones C. absence of glucose D. presence of red blood cells
decreased specific gravity
Which piece of equipment will the nurse remove from the bedside of a client on seizure precautions? A. oxygen B. padded tounge blade C. suction tubing and canister D. airway management equipment
padded tounge blade
The nurse is teaching a client about the manifestations and emergency management of hypoglycemia. Which response by the client indicates a correct understanding of what to do if the client feels hungry and shaky? A. "I will drink a glass of water." B. "I will eat three graham crackers." C. "I will give myself 1 mg of glucagon." D. "I will sit down and rest."
"I will eat three graham crackers."
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? A. "is your job demanding or stressful most of the time?" B. "Do you participate in any strenuous sports activities on a regular basis?" C. "Does anyone in your family have a history of central nervous system (CNS) problems?" D. "Were you aware of anything different or unusual just before your seizure began?"
"Were you aware of anything different or unusual just before your seizure began?"
Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A. A client with sensory neuropathy who needs teaching about foot care B. A client with diabetic ketoacidosis who has an IV running at 250 mL/hr C. A client who needs blood glucose monitoring and insulin before each meal D. A client who was admitted with fatigue and shortness of breath
A client who needs blood glucose monitoring and insulin before each meal
Which assessment findings are associated with Cushing disease? Select all that apply. A. Round face B. Dependent edema in the feet and ankles C. Increased fatty deposition in the extremities D. Thin, translucent skin with bruising E. Increased fatty deposition in the neck and back
A. Round face B. Dependent edema in the feet and ankles D. Thin, translucent skin with bruising E. Increased fatty deposition in the neck and back
A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? Select all that apply) A. constipation B. weight loss C. anorexia D. bradycardia E. heat intolerance F. palpitations
B. weight loss E. heat intolerance F. palpitations
Which responses would the nurse expect a client who has Addison's Disease who is in crisis (Addisonian Crisis)? Select all that apply. A. Bradycardia B. Hypertension C. Hyperkalemia D. Hyponatremia E. Postural hypotension
C. Hyperkalemia D. Hyponatremia E. Postural hypotension
Which outcome is the main focus of treatment for a client with Addison disease? A. Decrease in eosinophils B. Increase in lymphoid tissue C. Restoration of electrolyte balance D. Improvement of carbohydrate metabolism
Restoration of electrolyte balance
A nurse is providing health teaching to the patents of a 2 year old child who has been diagnosed with benign febrile seizures. What is the most important information for the nurse to give the parents about this disorder? A. a respiratory or ear infection is usually present B. it will result in developmental delay for the child C. this diagnosis usually progresses to one of epilepsy D. the seizures will continue throughout the child's life
a respiratory or ear infection is usually present
The client had a three-minute seizure and has no apparent injuries. The client is lethargic, orientated to name, place and time. The client says several times "just leave me alone and let me sleep". Which action by the nurse is the most appropriate? A. wake the client every 30 minutes B. perform a complete neurological examination C. administer PRN dose of lorazepam (Ativan) D. allow the client to sleep
allow the client to sleep
After teaching a group of students about diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic nonketotic syndrome (HHNKS), the instructor determines that additional teaching is needed when the students identify which of the following as characteristic of HHNKS? A. blood glucose level over 500mg/dL B. normal serum potassium levels C. decreased serum sodium levels D. blood pH level between 7.35-7.45
blood glucose level over 500mg/dL
A client reports extremely frequent urination, sometimes urinating 10-12 times each day. What fluid balance disorder would be expected with these symptoms? A. diluted urine B. hyponatremia C. dehydration D. hypokalemia
dehydration
A 8-year old begins to have a seizure while walking to the bathroom. What is the nurse's first action? A. ease the child to the floor and turn him on his side B. notify emergency medical services C. administer 10mg diazepam PR D. notify the child's parents so they can be with their child
ease the child to the floor and turn him on his side
A patient with diabetic ketoacidosis (DKA) has has a large volume of fluid infused for rehydration and insulin treatment started. What potential complication from rehydration and insulin treatment should the nurse monitor for? A. hypokalemia B. hypernatremia C. hyperkalemia D. hyperglycemia
hypokalemia
Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene? A. spinal shock B. brain herination C. hypovolemic shock D. increased intracranial pressure
increased intracranial pressure
A client is admitted with diabetic ketoacidosis (DKA). Which order from the physician should the nurse implement first? A. start an infusion of regular insulin at 50U/hr. B. adminster sodium bicarbonate 50 mEq IV push C. infuse 0.9% normal saline solution 1L/hr for 2 hours D. administer regular insulin 30 U IV push
infuse 0.9% normal saline solution 1L/hr for 2 hours
The nurse is admitting a client diagnosed with diabetic ketoacidosis (DKA). What is the nurse's priority intervention? A. subcutaneous glucagon administration B. transfusion of whole blood C. glucocorticoid administration D. intravenous insulin
intravenous insulin
Which action would the nurse take if a 6-year-old who is sitting at a table in the playroom has a tonic-clonic seizure with clenched jaws? A. lowering the child to the floor B. attempting to open the child's jaw C. placing a large pillow under the client's head D. going to the nurse's station to request assistance
lowering the child to the floor
The nurse is instructing the student nurse the plan of care for a client with a stroke that has dysphagia. Which of the following would the student question? A. feed the client slowly B. offer thin liquids frequently C. give foods with the consistency of oatmeal D. place food on unaffected side of the mouth
offer thin liquids frequently
An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? A. urine output B. 12-lead ECG C. potassium level D. rate of IV fluids
potassium level
A nurse teaches a group of grade-school teachers about seizures. The teachers role-play a scenario involving a child experiencing a tonic-clonic seizure. Which action by the educators, indicates that the nurse's teaching has been effective? A. removed any nearby objects that could hard the child B. inserted a padded tongue blade between the child's teeth C. moved the child to the nurse's office for privacy D. held the child's arms and legs to protect the child from injury
removed any nearby objects that could hard the child
How would the nurse describe the clonic phase of a tonic-clonic seizure? A. generalized rigidity B. loss of consciousness C. rhythmic body jerking D. tremors of upper extremities
rhythmic body jerking
Status epilepticus develops in an adolescent with a seizure disorder who is taking anti-seizure medication. Which reason would the nurse identify as the most common reason for the development of status epilepticus? A. the provider failed to account for a growth spurt B. the amount prescribed is insufficient to cover activities C. the prescribed anti-seizure medication probably is not taken consistently D. the client is prescribed a medication that is ineffective in preventing seizures
the prescribed anti-seizure medication probably is not taken consistently
The nurse is communicating with a client who has aphasia after having a stroke. What is the nurse's correct action? A. speak louder than normal voice B. turn the television volume down while speaking C. use long sentences to command the client's participation D. speak to the client without establishing eye contact
turn the television volume down while speaking
The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 82 mg/dL (mmol/L) and hemoglobin A1C of 5.9%. What is the nurse's interpretation of these findings? A. The client's glucose control for the past 24 hours has been good, but the overall control is poor. B. The client's glucose control for the past 24 hours has been poor, but the overall control is good. C. The values indicate that the client has poorly managed his or her disease. D. The values indicate that the client has managed his or her disease well.
D. The values indicate that the client has managed his or her disease well.
A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload? A. dyspnea and hypertension B. pulmonary congestion and muscle cramps C. confusion and diarrhea D. hypertension and weight gain without edema
dyspnea and hypertension
A nurse is caring for a client who sustained a head injury in a motor vehicle accident. The client has become restless and agitated over the past two hours. Which of the following is the priority nursing action? A. document assessment findings B. obtain an order for 2mg lorazepam to be given STAT IVP C. perform a focused neurological assessment and notify the health care provider of findings D. reorient client to surroundings and darken room to decrease outside stimulation
perform a focused neurological assessment and notify the health care provider of findings
An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. Which would the nurse tell the girl that may help her wear the bracelet consistently? A. hid the bracelet under long-sleeved clothes B. wear the bracelet when engaging in contact sports C. ask her friends to wear bracelets that look like hers D. select a bracelet similar to bracelets worn by her peers
select a bracelet similar to bracelets worn by her peers
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent dysrhythmias? A. serum potassium level B. serum calcium levels C. serum sodium levels D. serum chloride levels
serum potassium level
Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes? A. the client continues medication therapy despite adequate food intake B. the client has not consumed sufficient calories C. the client has been exercising more than usual D. the client has eaten and has not taken or received insulin
the client has eaten and has not taken or received insulin
A client is diagnosed with Cushing syndrome. The nurse would monitor the client for which cardiovascular complication? A. Chest pain B. Tachycardia C. Hypertension D. Atrial fibrillation
Hypertension
At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? A. weight gain B. fragile skin C. fatigue D. joint pain
weight gain
A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? A. "It is overwhelming, isn't it?" B. "Let's see how much you can learn today, so you are less nervous." C. "Let's tackle it piece by piece. What is most scary to you?" D. "Many people live with diabetes and do it just fine."
"Let's see how much you can learn today, so you are less nervous."
The client with a seizure disorder receives intravenous phenytoin. The nurse will monitor closely for which condition? A. cardiac dysrhythmias B. hypoglycemia C. polycythemia D. paradoxical excitation
cardiac dysrhythmias
A patient has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following would be expected in this patient? A. concentrated urine B. dilute urine C. hypernatremia D. increased serum osmolality
concentrated urine
A child undergoing prolonged steroid therapy takes on a cushingoid appearance. The nurse would expect to find which of these manifestations during further assessment? Select all that apply. A. Truncal obesity B. Thin extremities C. Increased linear growth D. Loss of hair on the body E. Decreased blood pressure
A. Truncal obesity B. Thin extremities
A patient has been diagnosed with Cushing's syndrome. The nurse would expect which of the following features to be present upon physical examination? (Select all that Apply) A. buffalo hump B. moon face C. thin extremities D. truncal obesity E. purple striae
A. buffalo hump B. moon face C. thin extremities D. truncal obesity E. purple striae
Which nursing action will the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? A. Assist the client's spouse in choosing appropriate dietary items. B. Evaluate the client's use of a home blood glucose monitor. C. Inspect the extremities for evidence of poor circulation. D. Assist the client with washing the feet and applying moisturizing lotion.
Assist the client with washing the feet and applying moisturizing lotion.
A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action will the nurse take first? A. Check the blood glucose. B. Administer oxygen. C. Offer reassurance. D. Attach a cardiac monitor.
Check the blood glucose.
The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? A. Client taking repaglinide (Prandin) who has nausea and back pain B. Client taking glyburide (Diabeta) who is dizzy and sweaty C. Client taking metformin (Glucophage) who has abdominal cramps D. Client taking pioglitazone (Actos) who has bilateral ankle swelling
Client taking glyburide (Diabeta) who is dizzy and sweaty
The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? A. Client with type 1 diabetes whose insulin pump is beeping "occlusion" B. Newly diagnosed client with type 1 diabetes who is reporting thirst C. Client with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L) D. Client with type 2 diabetes with a blood pressure of 150/90 mm Hg
Client with type 1 diabetes whose insulin pump is beeping "occlusion"
The nurse is caring for a client with Addison disease. Which dietary modification should the nurse include in the client's teaching plan? A. Increase potassium intake to replace renal losses. B. Increase protein intake to heal the adrenal tissue and thus cure the disease. C. Take supplemental vitamins to supply energy and assist in regaining the weight that was lost. D. Consume extra salt to replace the amount being lost due to a lack of sufficient aldosterone needed to conserve sodium.
Consume extra salt to replace the amount being lost due to a lack of sufficient aldosterone needed to conserve sodium.
Which electrolyte imbalance response would the nurse assess for in a client with a diagnosis of Cushing syndrome? A. Hypovolemia B. Hyperkalemia C. Hypoglycemia D. Hypernatremia
Hypernatremia
Which manifestations are exhibited with syndrome of inappropriate secretion of antidiuretic hormone (SIADH)? A. Increased blood urea nitrogen (BUN) and hypotension B. Hyperkalemia and poor skin turgor C. Hyponatremia and decreased urine output D. Polyuria and increased specific gravity of urine
Hyponatremia and decreased urine output
Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes? A. "Avoid drinking ice-cold beverages." B. "Be sure to check your blood pressure twice daily." C. "Change positions slowly when moving from sitting to standing." D. "Check your hands and feet weekly for areas of numbness or sensation change."
"Change positions slowly when moving from sitting to standing."
The nurse administers desmopressin acetate (DDAVP) to a client with diabetes insipidus. Which would the nurse monitor to evaluate the effectiveness of the medication? A. Arterial blood pH B. Intake and output C. Fasting serum glucose D. Pulse and respiratory rates
Intake and output
The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? A. "I will go barefoot in my house so that my feet are exposed to air." B. "I must inspect my shoes for foreign objects before putting them on." C. "I will soak my feet in warm water to soften calluses before trying to remove them." D. "I must wear canvas shoes as much as possible to decrease pressure on my feet."
"I must inspect my shoes for foreign objects before putting them on."
Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? A. American Diabetes Association (ADA) B. Centers for Disease Control and Prevention C. Primary health care provider office D. Pharmaceutical representative
American Diabetes Association (ADA)
A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? A. Instruct the client to continue with the current diet and metformin use. B. Discuss the need to check blood glucose several times every day. C. Talk about the possibility of adding rapid-acting insulin to the regimen. D. Ask the client about current dietary intake and medication use.
Ask the client about current dietary intake and medication use.
The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? A. Current lifestyle B. Educational and literacy level C. Sexual orientation D. Current energy level
Educational and literacy level
A client is admitted to the hospital with the diagnosis of cancer of the thyroid, and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period? A. Hypercalcemia may result from parathyroid damage. B. Hypotension and bradycardia may result from thyroid storm. C. Tetany may result from underdosage of thyroid hormone replacement. D. Hoarseness and airway obstruction may result from laryngeal nerve damage.
Hoarseness and airway obstruction may result from laryngeal nerve damage.
While in the playroom a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. What is the best action for the nurse to take after moving the child to the floor? A. Moving objects away from the child B. Taking the other children to their rooms C. Inserting a plastic airway into the child's mouth D. Positioning a large pillow under the child's head
Moving objects away from the child
The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? A. Perform a blood glucose check on a client who requires insulin. B. Verify the infusion rate on a continuous infusion insulin pump. C. Assess a client who reports tremors and irritability. D. Monitor a client who is reporting palpitations and anxiety.
Perform a blood glucose check on a client who requires insulin.
A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? A. "Your diabetes is getting worse, so you will need to take insulin." B. "You can't take your metformin while in the hospital." C. Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." D. "You must take insulin from now on because the surgery will affect your diabetes."
Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily."
The nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? A. Most clients with type 1 diabetes are born with it. B. People with type 1 diabetes are often obese. C. Those with type 2 diabetes make insulin, but in inadequate amounts. D. People with type 2 diabetes do not develop typical diabetic complications.
Those with type 2 diabetes make insulin, but in inadequate amounts.
A nurse is reviewing laboratory reports of a client who has HHS. Which of the following findings should the nurse expect? A. blood pH 7.2 B. blood osmolarity 350 mOsm/L C. blood potassium 3.8 mg/dL D. blood creatinine .8 mg/dL
blood osmolarity 350 mOsm/L
A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? A. "Keep up the good work." B. "This is not good at all." C. "Have you been doing something differently? D. "You need an increase in your insulin dose."
"Have you been doing something differently?
The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? A. "I can break in my shoes by wearing them all day." B. "I need to monitor my feet daily for blisters or skin breaks." C. "I will never go barefoot." D. "I need to quit smoking."
"I can break in my shoes by wearing them all day."
The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? A. Add 20 mEq of KCl to each liter of IV fluid B. IV regular insulin at 2 units/hr C. IV normal saline at 100 mL/hr D. 1 ampule Sodium Bicarbonate IV now
1 ampule Sodium Bicarbonate IV now
Which aspects would the nurse assess to determine increasing intracranial pressure around the medulla? Select all that Apply A. taste B. breathing C. heart rate D. fluid balance E. voluntary movement
B. breathing C. heart rate
Which of these assessments lead the nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure? Select all that Apply A. irritability B. high-pitched cry C. depressed fontanels D. decreased urinary output E. ineffective feeding behavior
B. high-pitched cry E. ineffective feeding behavior
Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? A. 75-year-old client whose blood glucose levels show little variation B. 55-year-old client who has hypoglycemic unawareness C. 80-year-old client with type 2 diabetes mellitus D. 45-year-old client with type 1 diabetes mellitus
55-year-old client who has hypoglycemic unawareness
When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which medication will the nurse expect the health care provider to prescribe? A. Calcium B. Magnesium C. Bicarbonate D. Potassium chloride
Calcium
The nurse is caring for a client hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which action performed by the nurse may result in a positive outcome of the treatment? A. Obtaining the client's weight weekly B. Elevating the head of the bed to 20 degrees C. Changing the position of the client frequently D. Restricting the client's total fluid intake to 250 mL/day
Changing the position of the client frequently
The clinic nurse is providing teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? A. "If I become hyperglycemic, it is a medical emergency." B. "If I become hypoglycemic, I could become unconscious." C. "Medical personnel may need confirmation of my insurance." D. "I may need to be admitted to the hospital suddenly."
"If I become hypoglycemic, I could become unconscious."
Which interventions would the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? (Select all that apply) A. Provide frequent oral care. B. Institute fall risk precautions. C. Restrict fluids to 2 L per day. D. Place the client in high-Fowler position. E. Monitor for and report neurological changes.
A. Provide frequent oral care. B. Institute fall risk precautions. E. Monitor for and report neurological changes.
The nurse is teaching a client with newly diagnosed type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? A. "I will begin exercising for at least an hour a day." B. "I will monitor my diet and avoid empty calories." C. "If I lose weight, I may not need to use the insulin anymore." D. "Weight loss can be a sign of diabetic ketoacidosis."
"I will begin exercising for at least an hour a day."
A client with a seizure disorder is receiving phenytoin and phenobarbital. Which client statement indicates that the instructions regarding the medications are understood? A. "I will not have any seizures with these medications" B. "These medicines must be continued to prevent falls and injury" C. "Stopping the medications can cause continuous seizures and I may die" D. "By my staying on the medicines I will prevent post-seizure confusion"
"Stopping the medications can cause continuous seizures and I may die"
Which finding in a client with hypothyroidism and hypertension who reports taking an extra dose of levothyroxine indicates the need to obtain a thyroid function panel? Select all that apply. A. Tremors B. Diaphoresis C. Nervousness D. Temperature 96.1°F E. Heart rate 116 beats/min
A. Tremors B. Diaphoresis C. Nervousness E. Heart rate 116 beats/min
Which finding would be expected in a client with a history of hypothyroidism? Select all that apply. A. Cold intolerance B. Lethargy C. Fatigue D. 15-pound weight gain E. Heart rate 59 beats/min
A. Cold intolerance B. Lethargy C. Fatigue D. 15-pound weight gain E. Heart rate 59 beats/min
A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing DKA? (Select all that Apply) A. drink 2L fluids daily B. monitor blood glucose every 4 hours when ill C.administer insulin as prescribed when ill D. notify the provider when blood glucose is 200 mg/dL E. report ketones in the urine after 24 hours of illness
A. drink 2L fluids daily B. monitor blood glucose every 4 hours when ill C.administer insulin as prescribed when ill E. report ketones in the urine after 24 hours of illness
Which clinical findings would the nurse expect to see when assessing a client with hyperthyroidism? Select all that apply. A. Dry skin B. Weight loss C. Tachycardia D. Restlessness E. Constipation F. Exophthalmos
B. Weight loss C. Tachycardia D. Restlessness F. Exophthalmos
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse? A. inserting an oral airway B. administering oxygen by mask C. continuing to observe the seizure D. notify the doctor immediately
continuing to observe the seizure
An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? A. administration of antihypertensive medications B. administering sodium bicarbonate intravenously C. reversing acidosis by administering insulin D. fluid and electrolyte replacement
fluid and electrolyte replacement
A client recently admitted with new-onset type 2 diabetes will be discharged with a meter for self-monitoring of blood glucose (SMBG) levels. When is the best time for the nurse to explain to the client the proper use of the glucose monitor? A. day of discharge B. on admission C. when the client states readiness D. while preforming the test in the hospital
while preforming the test in the hospital
The nurse is planning care for a client with diabetes insipidus (DI). Which intervention made by the nurse requires correction? A. Assessing sodium levels B. Measuring urine output C. Restricting fluids at night D. Changing positions slowly
C. Restricting fluids at night
A client diagnosed with status epilepticus has orders to be placed under seizure precautions. Which of the following are part of the plan of care? (Select all that Apply) A. IV access via saline lock B. oral airway to maintain oxygenation C. suction equipment at bedside D. restraints to protect the client from injury
A. IV access via saline lock C. suction equipment at bedside
Which symptoms indicating thyroid storm would the nurse monitor a client for? Select all that apply. A. Increased heart rate B. Increased temperature C. Decreased respirations D. Increased pulse deficit E. Decreased blood pressure
A. Increased heart rate B. Increased temperature
A client newly diagnosed with diabetes is not ready to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? (Select all that apply) A. Pathophysiology of diabetes B. Causes and treatment of hypoglycemia C. Dietary control of blood glucose D. Insulin administration E. Physical activity and exercise
B. Causes and treatment of hypoglycemia D. Insulin administration
A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. the nurse should expect which of the following findings? (Select all that Apply) A. weight gain B. fruity odor of breath C. abdominal pain D. kussmaul respirations E. metabolic acidosis
B. fruity odor of breath C. abdominal pain D. kussmaul respirations E. metabolic acidosis
The nurse is caring for a client at risk for an Addisonian crisis. For what associated signs and symptoms should the nurse monitor the client? (Select all that Apply) A. epistaxis B. rapid respiratory rate C. bounding pulse D. hypotension E. rapid, weak pulse
B. rapid respiratory rate D. hypotension E. rapid, weak pulse
Which signs and symptoms might the nurse identify when assessing a client with hyperthyroidism? Select all that apply. A. Menstrual irregularities B. Hypotension C. Facial edema D. Flushed appearance E. Short attention span
A. Menstrual irregularities D. Flushed appearance E. Short attention span
Which physiologic actions result from normal insulin secretion? (Select all that apply) A. Increased liver storage of glucose as glycogen B. Increased gluconeogenesis C. Increased cellular uptake of blood glucose D. Increased breakdown of lipids (fats) for fuel E. Increased production and release of epinephrine F. Decreased storage of free fatty acids in fat cells G. Decreased blood glucose levels H. Decreased blood cholesterol levels
A. Increased liver storage of glucose as glycogen C. Increased cellular uptake of blood glucose G. Decreased blood glucose levels H. Decreased blood cholesterol levels
Which symptoms are most often seen in hypothyroidism? (Select all that Apply) A. constipation B. weight gain C. exophthalmia D. hypotension E. cold intolerance F. tremors G. palpitations H. increased appeitie
A. constipation B. weight gain D. hypotension E. cold intolerance
A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemic hyperosmolar state (HHS)? (Select all that Apply) A. evidence of recent myocardial infarction B. BUN 35 mg/dL C. takes a calcium channel blocker D. age 77 years E. daily insulin injections
A. evidence of recent myocardial infarction B. BUN 35 mg/dL C. takes a calcium channel blocker D. age 77 years
A patient has been placed on corticosteroid therapy for an Addison's disease. The nurse should be aware of which of the following side effects with this type of therapy? (Select all that Apply) A. hypertension B. alterations in glucose metabolism C. poor wound healing D. hypotension E. weight loss
A. hypertension B. alterations in glucose metabolism C. poor wound healing
Which are correct statements about the relationship between the hypothalamus and the pituitary gland? (Select all that apply) A. many endocrine glands respond to stimulation from the pituitary gland, which is connected by a stalk to the hypothalamus in the brain B. under the influence of the hypothalamus, the lobes of the pituitary gland secrete various hormones C. the pituitary gland is called the master gland because it regulates the function of the hypothalamus and other endocrine glands D. the hypothalamus is called the master gland because it controls the function of the pituitary gland
A. many endocrine glands respond to stimulation from the pituitary gland, which is connected by a stalk to the hypothalamus in the brain B. under the influence of the hypothalamus, the lobes of the pituitary gland secrete various hormones
Which clincial indicators would the nurse consider evidence of increased intracranial pressure? Select all that Apply A. vomiting B. irritability C. hypotension D. increased respirations E. decreased level of consciousness
A. vomiting B. irritability E. decreased level of consciousness
A nurse is planning care for a client who has Cushing's disease. The nurse recognizes that clients who have Cushing's disease are at increased risk for which of the following? (Select all that apply) A. renal calculi B. dysphagia C. infection D. hirsutism E. gastric ulcer F. bone fractures
C. infection D. hirsutism E. gastric ulcer F. bone fractures
After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate antidiuretic hormone (SIADH). For which clinical indicators would the nurse monitor the client? (Select all that apply) A. Polyuria B. Insomnia C. Bradycardia D. Increased weight E. Decreased serum sodium F. Decreased level of consciousness
D. Increased weight E. Decreased serum sodium F. Decreased level of consciousness
The nurse is reviewing the laboratory and diagnostic test findings of a client diagnoses with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following would the nurse expect to find? A. elevated serum sodium levels B. decreased serum osmolarity C. decreased urine sodium levels D. elevated urine calcium levels
decreased serum osmolarity
A client with a hemorrhagic stroke and increased intracranial pressure is admitted to the intensive care unit. Which of the following actions should the nurse include in the client's plan of care? A. turn client every four hours B. suction frequently to maintain a clear airway C. elevate the head of bed to 30 degrees D. PRN use of sequential compression devices
elevate the head of bed to 30 degrees
Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures? A. ensuring patent airway B. administering intravenous fluids C. monitoring level of consciousness D. protecting the client from injury during seizures
ensuring patent airway
The nurse assesses a client diagnosed with acute subdural hematoma. Which assessment finding would the nurse report to the healthcare provider? A. headache B. generalized weakness C. nausea D. unable to state current year
generalized weakness
Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction experiences: A. heat intolerance and systolic hypertension B. weight gain and heat intolerance C. diastolic hypertension and widened pulse pressure D. anorexia and hyperexcitability
heat intolerance and systolic hypertension
A nurse is reviewing the medical record for a client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? A. administer an IV infusion of regular insulin at 0.3 units/kg/hr B. administer a slow IV infusion of 3% sodium chloride C. rapidly adminster an IV infusion of 0.9% sodium chloride D. add glucose to the IV infusion when blood glucose is 350 mg/dL
rapidly adminster an IV infusion of 0.9% sodium chloride
A primary health care provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation would the nurse provide to the client about the need to follow this diet? A. "The use of salt probably contributed to the disease." B. "Excess weight will be gained if sodium is not limited." C. "The loss of excess sodium and potassium in the urine requires less renal stimulation." D. "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
"Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
