Adult Health - Archer Review (5/8) - Endocrine and Immune
Choice C is correct. Following a thyroidectomy, one of the most serious complications is an ineffective airway due to tracheal compression, hematoma, and/or edema. Therefore, it is essential to have a tracheostomy set, oxygen, and suction available at the bedside for at least the initial 24-hour post-operative period.
A 28-year-old post-thyroidectomy client is transferred from the post-anesthesia care unit to the medical-surgical floor. Which action demonstrates the medical-surgical nurse understands the possible complications of a thyroidectomy? A. Dressings are changed every two hours to best detect post-operative bleeding, so the nurse should place the dressings at the bedside. B. Pain is managed immediately upon the client's return to the room by promptly administering a narcotic medication. C. The bedside is prepared with a tracheostomy set, oxygen, and suction. D. The nurse teaches the client alternative means of communication upon arrival to the room.
Choice B is correct. Anaphylaxis is an acute, potentially life-threatening, IgE-mediated allergic reaction occurring in previously sensitized clients following reexposure to the sensitizing antigen. Hypersensitivity reactions occur when antibodies are formed through previous exposure to an allergen. Therefore, based on this information, this client has, at some point (either during this admission or at some point in the past), received penicillin previously. Anaphylactic reactions do not typically occur after the initial exposure to an allergen (i.e., the substance that triggers an allergic reaction). Most often, anaphylaxis occurs following a client's subsequent exposure to the allergen. Of note, many clients do not recall their first exposure to the allergen in question (especially non-medicinal allergens).
A client in the medical ward developed sudden hypotension, difficulty breathing, and cyanosis shortly after receiving an intravenous penicillin infusion. Based on the nurses' understanding of anaphylactic reactions, what can the nurse conclude is the cause of this reaction? A. Potent antibodies formed when the antibiotic was infused into the client during this infusion. B. The client was previously exposed to penicillin, enabling their body to produce antibodies. C. The client developed passive immunity to penicillin. D. Atopic sensitization occurred.
Choice A is correct. A known side effect of systemic steroids, including hydrocortisone, is elevated glucose levels (hyperglycemia), due to the promotion of gluconeogenesis and the subsequent elevation of blood glucose levels. Therefore, the nurse should monitor the client's blood glucose levels frequently.
A post-adrenalectomy client is admitted to the intensive care unit and is on intravenous hydrocortisone. Which nursing intervention should be included in the client's plan of care? A. Monitor blood glucose levels frequently B. Keep the client supine for 24 hours C. Discontinue hydrocortisone once vital signs become stable D. Educate the client on how to properly clean the wound at home
Myxedema coma Hypothyroidism
Select the two (2) issues the client is at risk of developing if the symptoms go unrecognized and untreated? Thyrotoxicosis Hyperthyroidism Myxedema coma Hypothyroidism Graves' disease Adrenal insufficiency
She said she is still gaining weight and experiencing constipation. Trace pedal edema was noted Hypoactive bowel in all quadrants sounds with abdominal distention.
Six weeks later, the nurse reviews the client's progress note Click to highlight the findings in the progress note that indicate that the client is not meeting the treatment goals Note: Tap to highlight and select the answer. The client presents six weeks following the initiation of levothyroxine. The client reports that "she feels better but not 100%." She indicates that she is going outdoors more often and engaging with friends. She said she is still gaining weight and experiencing constipation. On exam, the client is alert and oriented. She reports that her mood is "good" and has a cheerful affect. Trace pedal edema was noted with 2+ peripheral pulses at a rate of 64/minute. Hypoactive bowel in all quadrants sounds with abdominal distention.
hypothyroidism
The client is at highest risk for developing ____
Choice D is correct. The client's presentation with angioedema (lip swelling) and dyspnea after a bee sting indicates anaphylaxis, an acute antibody-antigen reaction that can lead to life-threatening multi-system involvement. Anaphylaxis is characterized by bronchoconstriction, angioedema, abdominal cramps, urticaria, and distributive shock. The client is at risk for airway compromise from angioedema, and immediate administration of epinephrine is recommended to prevent airway closure. Intramuscular (IM) administration of epinephrine is preferred over the intravenous (IV) route because there is a higher risk of cardiac complications with IV administration.
The emergency department nurse is caring for a client with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The nurse knows that the first-line medication for this presentation is: A. Oral diphenhydramine B. Nebulized albuterol C. Oral prednisone D. Parenteral epinephrine
Choice C is correct. For a client with Guillain-Barre syndrome, the nurse is concerned about the paralysis potentially involving the diaphragm. Paralysis of the diaphragm may lead to respiratory failure, and the nurse should ensure that oral intubation equipment is readily available if the paralysis impacts the diaphragm.
The intensive care unit (ICU) nurse is preparing to admit a client with Guillain-Barre syndrome. Which of the following items is essential for the nurse to have at the client's bedside? A. blood pressure cuff B. pulse oximeter C. oral intubation equipment D. arterial blood gas (ABG) supplies
Choice A is correct. Raynaud's phenomenon (RP) results from vascular spasms in the fingers that are triggered by cold temperatures and emotional stress.
The nurse is assessing a client who has Raynaud's phenomenon. Which of the following would be an expected finding? A. Digit color changes B. Flapping hand tremor C. Painless skin ulcers D. Janeway lesions
Choice D is correct. Primary Cushing's disease is characterized by hypersecretion of ACTH from the pituitary gland, which is usually due to a pituitary adenoma. This causes the client to experience multisystem manifestations such as sodium and water retention leading to weight gain, elevated blood glucose, delayed wound healing, and increased gastric acid secretion.
The nurse is preparing a presentation on Cushing's disease. It would be correct if the nurse states that Cushing's disease is caused by A. destruction to pancreatic beta cells. B. excessive discharge of thyroid-stimulating hormone (TSH). C. decrease in the secretion of androgens and glucocorticoids. D. increase in the secretion of adrenocorticotropin hormone (ACTH).
Choice A is correct. Cell-mediated immunity is the best illustration of natural adaptive immunity. This immunity is spurred by cytokines and T-lymphocytes and doesn't include antibodies.
The nurse is providing teaching to a student nurse about the immune system. Which of the following is the best example of natural adaptive immunity? A. Cell-mediated response B. Lymphocyte creation C. Inflammatory response D. The flu vaccine
Choices A, B, C, and D are correct. A is correct. Insulin is typically administered subcutaneously. Intramuscular injection can lead to unpredictable absorption rates and potential for hypoglycemia. B is correct. Regular insulin is the only type of insulin that can be administered intravenously, which may be done in emergency situations such as diabetic ketoacidosis, where rapid control of blood glucose is needed. C is correct. Regular rotation of insulin injection sites within the same general area (like the abdomen or thighs) is recommended to prevent lipohypertrophy, a thickening or lump under the skin caused by repeated injections at the same site, which can affect insulin absorption. D is correct. Long-acting insulins (glargine and detemir) should not be mixed with other insulins in the same syringe due to their pH or potential for precipitation, which could affect their action.
The nurse is teaching a new group of nurses about insulin administration for a client with type I diabetes mellitus. Which of the following points should be included? Select all that apply. Administer insulin subcutaneously, not intramuscularly. Regular insulin can be administered intravenously in emergency situations. Rotate injection sites to prevent lipohypertrophy. Long-acting insulin should not be mixed in the same syringe with other types of insulin It's safe to administer cold insulin directly from the refrigerator.
Choice A is correct. One of the clinical features of a myxedema coma is hypothermia. Passive warming of the client is an effective treatment measure for this emergency. Cooling the client would require follow-up as this would worsen the hypothermia.
The nurse preceptor observes a newly hired nurse care for a client with a myxedema coma. It would require follow up by the nurse preceptor if the newly hired nurse is observed A. applying a cooling blanket to the client. B. requesting a prescription for hydrocortisone. C. removing the water pitcher from the bedside. D. placing an oral endotracheal tube at the bedside for potential use.
Weight gain Thyroid stimulating hormone (TSH) level Thyroxine (T4) level Flattened affect
The nurse reviews the history and physical and laboratory data Select four (4) client findings that require follow-up Glasgow coma scale Weight gain Triiodothyronine (T3) level Thyroid stimulating hormone (TSH) level Thyroxine (T4) level Peripheral pulses Flattened affect Lung sounds
Choice B is correct. The elderly experience increased autoimmune responses. This increases the risk of diseases such as rheumatoid arthritis and other collagen disorders.
Which of the following are clinical manifestations of the aging immune system and should alert the nurse of increased susceptibility to illness? A. Increased lymph tissue B. Increased autoimmune responses C. Increased circulation of lymphocytes D. Increased T and B cell production
Choice B is correct. Hydrochlorothiazide is a thiazide diuretic and has a paradoxical effect when prescribed for individuals with diabetes insipidus. While commonly HCTZ causes a diuretic effect, when used for nephrogenic DI, it can increase the proximal sodium and water reabsorption, thereby reducing the urine output.
The nurse is caring for a client who has nephrogenic diabetes insipidus. Which of the following medications should the nurse expect to be prescribed for the client? A. Prednisone B. Hydrochlorothiazide C. Verapamil D. Lithium
Choice C is correct. Grave's disease is the most common cause of hyperthyroidism. It is characterized by increased heart rate, excessive sweating, heat intolerance, exophthalmos (bulging eyeballs), fatigue, tachycardia, shortness of breath, fine muscle tremors, thin silky hair/skin, and infrequent blinking.
The nurse is caring for a client who reports diarrhea, unintentional weight loss, and nervousness. The primary healthcare provider (PHCP) orders a thyroid panel, and the nurse understands the client is at the highest risk for A. Myxedema B. Bell's palsy C. Grave's disease D. Cushing syndrome
Choice D is correct. The ABG depicts metabolic acidosis, which is an expected finding with DKA. Metabolic acidosis develops with DKA because fats are used as fuel because of the absence of insulin. This causes ketones to be produced, creating a state of acidosis.
The nurse is working in the emergency department caring for a client with diabetic ketoacidosis (DKA). Which of the following arterial blood gas (ABG) results would be expected? A. pH = 7.50; PaO2 = 90 mm Hg; PaCO2 = 37 mm Hg; HCO3- = 31 mEq/L B. pH = 7.31; PaO2 = 90 mm Hg; PaCO2 = 56 mm Hg; HCO3- = 23 mEq/L C. pH = 7.51; PaO2 = 94 mm Hg; PaCO2 = 31 mm Hg; HCO3- = 24 mEq/L D. pH = 7.31; PaO2 = 90 mm Hg; PaCO2 = 37 mm Hg; HCO3- = 15 mEq/L
Inspect the bottle for the type of insulin and the expiration date. Gently roll the bottle of intermediate-acting insulin in the palms of your hands to mix the insulin. Clean the rubber stopper with an alcohol swab. Pull back the plunger to draw air into the syringe and inject it into the vial. Turn the bottle upside down and draw the insulin dose into the syringe. Remove air bubbles in the syringe by tapping on the syringe.
The nurse prepares to administer intermediate-acting insulin to a client with diabetes mellitus. Arrange the steps in the order that the nurse must perform them when preparing the injection. All options must be used. Press and hold an option to rearrange Remove air bubbles in the syringe by tapping on the syringe. Gently roll the bottle of intermediate-acting insulin in the palms of your hands to mix the insulin. Pull back the plunger to draw air into the syringe and inject it into the vial. Inspect the bottle for the type of insulin and the expiration date. Clean the rubber stopper with an alcohol swab. Turn the bottle upside down and draw the insulin dose into the syringe.
"I will need to consistently take this medication every morning." "I should call my doctor if I start to experience sweating and insomnia."
The nurse receives physician orders and reviews the discharge orders with the client Which of the following two (2) statements by the client would indicate a correct understanding of the teaching? "I plan to take this medicine with a high-protein meal." "I will need to consistently take this medication every morning." "I should call my doctor if I start to experience sweating and insomnia." "I will add in more low fiber foods to my diet." "I will need to take this medication for six weeks." "I can help manage my fatigue by doing all of my activites at once instead of spacing them out."
Choice D is correct. Sympathectomy severs the paths to the sympathetic division of the autonomic nervous system. The outcomes of this procedure include improvement in vascular blood supply and the elimination of vasospasm. It is used to treat the pain from vascular disorders, such as Raynaud's disease. Raynaud's phenomenon is a problem that causes decreased blood flow to the fingers. In some cases, it also causes less blood flow to the ears, toes, nipples, knees, or nose. This happens due to spasms of blood vessels in those areas. The seizures occur in response to cold, stress, or emotional upset. Raynaud's can occur on its own, known as the primary form or it may happen along with other diseases, known as the secondary form. The conditions most often linked with Raynaud's are autoimmune or connective tissue diseases.
You are caring for a patient with Raynaud's disease who has intractable pain. The patient is scheduled to undergo surgical interruption of pain conduction pathways to improve vascular blood supply as well as eliminate vasospasm and pain. Which type of surgery is the patient most likely to undergo? A. Cordotomy B. Rhizotomy C. Neurectomy D. Sympathectomy
Choice C is correct. SIADH is an abnormal release of the antidiuretic hormone (ADH), which causes the client to retain water inappropriately. Because free water is retained, the sodium is diluted in the serum. The antidiuretic effect causes urine and plasma alterations such as:- Lower urine output Higher urine osmolality Higher urine-specific gravity (concentrated urine) Low serum osmolality Low serum sodium (hyponatremia) Physical exam findings often reveal Normal skin turgor (euvolemic) Weight gain without peripheral edema (SIADH causes fluid retention across all of the fluid compartments, not just in the extracellular space. So peripheral edema is absent) Blood pressure is mostly normal (normotensive) or slightly increased (choice C)
A client suddenly develops syndrome of inappropriate antidiuretic hormone (SIADH) after undergoing cranial surgery. Which of the following would be an expected finding? A. Peripheral edema B. Excessive urine production C. Normal or slightly increased blood pressure D. A low urine specific gravity
Choice D is correct. Cardiac output is essential to ensure adequate blood flow to all parts of the body. It is affected by the circulating blood volume and heart rate. If left unattended, a decreased pulse can lead to shock. It should take priority over all other nursing diagnoses.
A middle-aged man comes into the clinic for a check-up. His pulse is 49 beats per minute and the client reports that he has gained 20 pounds in the past two months. The nurse also notices that his skin is cool to touch and that he has three layers of clothing. The nurse suspects hypothyroidism. Which nursing diagnosis should be of the highest priority? A. Fatigue B. Activity intolerance C. Hypothermia D. Decreased cardiac output
Choice C is correct. For the client with type 1 diabetes mellitus, glucose levels will initially rise with exercise. The epinephrine released from the adrenal gland will cause the liver to discharge more glucose into the body. Prolonged exercise is likely to cause hypoglycemia because of the uptake of glucose from the muscles.
The nurse has instructed a client with type 1 diabetes mellitus about proper exercise. Which of the following client statements indicates a correct understanding of the teaching? A. "I should carry a snack rich in protein just in case I feel shaky." B. "I will not take my prescribed daily glargine insulin if I plan on exercising." C. "I can initially expect my glucose level to rise with vigorous exercise." D. "I should start my exercise near the time that my insulin peaks."
Choice C is correct. DI can be divided into either neurogenic (central) or nephrogenic. The water deprivation test is used to help differentiate whether the DI is neurogenic or nephrogenic. In this test, the client is deprived of water for up to eight hours (they may still eat dry foods). Serial labs, including plasma and urine osmolality measurements, are obtained during that time. Additionally, the client's urine volume and weight are meticulously measured hourly. If the client's body weight should decrease, this supports the diagnosis of DI. At the end of the eight hours, a dose of desmopressin is administered. If there is an increase in urine osmolarity and a decrease in urine volume, it is considered central/neurogenic DI (because the problem responded to the DDAVP). If no response is observed after the DDAVP is administered, nephrogenic DI is likely.
The nurse has received an order to prepare a client for a water deprivation test. The nurse understands that this test is used to diagnose A. hyperthyroidism B. pheochromocytoma C. diabetes insipidus (DI) D. syndrome of inappropriate antidiuretic hormone (SIADH)
Choice A is correct. Hypoglycemia is one of many clinical features of myxedema coma. Myxedema coma is a severe form of hypothyroidism and warrants immediate medical attention.
The nurse is assessing a client with a myxedema coma. Which of the following would be an expected finding? A. Glucose 59 mg/dL (3.2745 mmol/L) B. Sodium 155 mEq/L C. Serum pH 7.49 D. Temperature 102.4° F (39.1° C)
Choice A is correct. A lack of cortisol and aldosterone characterizes Addison's disease. The priority for the nurse is to administer the prescribed hydrocortisone to prevent the client from developing a life-threatening Addisonian crisis.
The nurse is caring for a client who has Addison's disease. Which of the following interventions would be a priority? A. Administer prescribed hydrocortisone B. Offer salty snacks and water C. Assess skin integrity D. Encourage frequent rest periods
Choice D is correct. The client's vital signs indicate hypovolemic shock. The tachycardia and hypotension that started at 11:00 AM have worsened, and the nurse should initiate prescribed intravenous fluids to restore circulating volume.
The nurse is caring for a client who has acute pancreatitis. Based on the 11:15 AM vital signs, the nurse should prioritize which action? See the image below. A. Obtain a 12-lead electrocardiogram B. Assess the client for pain C. Apply oxygen via nasal cannula D. Infuse 500 ml 0.9% sodium chloride bolus
Choices A, C, D, and F are correct. Blurred vision (Choice A), cool and clammy skin (Choice C), palpitations (Choice D), and paresthesias (Choice F) are expected findings with hypoglycemia. Hypoglycemia is a blood sugar less than 70 mg/dL. Symptoms of hypoglycemia can be divided into two broad categories: Neurogenic (autonomic): Adrenergic vs cholinergic symptoms: include those from the release of catecholamines such as tremors, palpitations (Choice D),anxiety (catecholamine-mediated, adrenergic), sweating, hunger, and paresthesias (Choice F) (acetylcholine-mediated, cholinergic). Neuroglycopenic: Neuroglycopenia refers to a deficiency of glucose in the brain and neurons secondary to hypoglycemia. Symptoms of moderate neuroglycopenia include blurred vision (Choice A), slurred speech, drowsiness, dizziness, and extreme fatigue. Severe neuroglycopenia can cause delirium, confusion, and eventually, seizure and coma.
The nurse is caring for a client who presents with a blood glucose level of 45 mg/dL (70-110 mg/dL). Which of the following findings are expected? Select all that apply. Blurred vision Increased urinary output Cool and clammy skin Palpitations Orthostatic hypotension Paresthesias
Choice A is correct. Given the available options, assessing respiratory is the highest priority nursing intervention for a client with Guillain-Barré syndrome experiencing ascending paralysis. The frequency of respiratory assessment will vary from client to client. GBS is a neurological disorder characterized by progressive muscle weakness and paralysis that can start from the legs and ascend upwards. As paralysis affects the muscles responsible for breathing, clients with GBS are at risk of developing respiratory insufficiency or failure.
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The nurse plans on taking which priority action? A. Assessing respiratory status frequently. B. Administering intravenous immunoglobulin (IVIG) as prescribed. C. Providing passive range of motion exercises to maintain joint mobility. D. Monitoring for autonomic dysreflexia.
Choices A, B, C, and E are correct. Type two diabetes mellitus is the most common type of diabetes worldwide. Risk factors for diabetes mellitus include gestational diabetes, metabolic syndrome, chronic corticosteroid use, and obesity. Individuals with gestational diabetes should be tested for diabetes mellitus, type II, within one year following their pregnancy.
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing type II diabetes mellitus? Select all that apply. Gestational diabetes Metabolic syndrome Chronic corticosteroid use Gastric bypass surgery Obesity
Choice C is correct. Regular (short-acting) insulin is clear. NPH (intermediate-acting) is cloudy. Giving one injection is more efficient and comfortable for the client. It is correct for the nurse to aspirate (which means remove) the regular insulin first, then aspirate the NPH insulin. This is performed after the air has been instilled in both vials, creating a negative pressure.
The nurse is preparing to administer ten units of regular insulin and twenty units of NPH insulin. Which of the following actions is correct when mixing the insulins? A. Aspirate the NPH insulin first B. Roll the regular insulin vial C. Aspirate the regular insulin first D. Instill air into the regular insulin vial first
Choice C is correct. The pneumococcal vaccine is a priority immunization among elderly clients and those with chronic illnesses. This vaccine should be administered every five years.
Which of the following immunizations is a priority for a client who is 75 years old and has a history of cerebrovascular disease? A. Hepatitis A vaccine B. Hepatitis B vaccine C. Pneumococcal vaccine D. Lyme disease vaccine
Choices A, B, C and E are correct. Educating the client and family is one of the primary functions of the registered nurse. The first step in this process is to assess the client's knowledge about the disease or condition. Is the information accurate and complete? If not, one of the goals in the process is to correct or supplement the knowledge. As the nurse talks with the client, it is essential to help the client identify what barriers they perceive to being able to control their disease. For example, a person with diabetes might think that they cannot afford the medications necessary to treat diabetes. If the client must give themselves injections, they might say that they won't be able to inject themselves due to fear. Once the barriers are identified, the nurse must develop a plan to overcome the obstacles. Often, this involves consulting with other team members. For example, a case manager might be called in to help with financial issues. A new diagnosis can be overwhelming. It is often helpful to suggest small behavior changes. For example, a diabetic client may indicate that they cannot change their eating habits. This might indicate to the nurse that a dietician consult would be
You are tasked with providing education to a 24-year-old newly diagnosed diabetic. The correct approach to providing this education is: Select all that apply. Assess the client's knowledge. Ask the client about their perception of barriers to controlling the disease. Suggest small behavior changes based on specific information. Provide "just-in-time" education at the time of discharge. Assess the client's preferred learning style
Choice B is correct. The theory of aging that supports your belief that strict infection control prevention measures are necessary is the 'Immunological Theory of Aging'. The 'Immunological Theory of Aging' states that aging leads to the decline of the person's defensive immune system and the decreased ability of the antibodies to protect us against infection. Programmed theories assert that the human body is designed to age and there is a certain biological timeline that bodies follow. All of these theories share the idea that aging is natural and "programmed" into the body. Error theories, such as the 'Rate of Living Theory', assert that aging is caused by environmental damage to the body's systems, which accumulates over time.
You are the nursing supervisor in a long-term care facility. One of the major considerations that you apply into your practice is strict infection control prevention measures because you are knowledgeable about the fact that the normal aging process is associated with the deterioration of the body's normal defenses. Which theory of aging supports your belief that strict infection control prevention measures are necessary? A. The Programmed Longevity Theory B. The Immunological Theory of Aging C. The Endocrine Theory D. The Rate of Living Theory
Choice D is correct. It is essential for the nurse to teach the client to return on a specified date to have the test results read by the health care provider (HCP). For a client undergoing skin hypersensitivity testing, test outcomes are determined based on specific hypersensitivity changes (i.e., erythema, wheals, and induration). Therefore, an essential aspect of skin hypersensitivity testing is ensuring the results are read at the appropriate intervals. Although the health care provider (HCP) can analyze immediate hypersensitivity reactions soon after the test is performed, delayed hypersensitivity reactions must be interpreted at a follow-up appointment specified by the HCP (typically 48-72 hours after the initial appointment). Interpretation of the test results before or after this particular timeframe would yield inaccurate and unreliable results. Therefore, the nurse should ensure the client is aware of the date and time of the follow-up appointment and understands the importance of adhering to the appointment to ensure their test results are correctly interpreted.
A nurse educates a client who just had a skin test for hypersensitivity reactions. The nurse should teach the client which of the following? A. Ensure that the tested areas are kept moist with a mild lotion B. Keep the tested skin regions out of direct sunlight until after the test has been read C. Wash the test sites daily with mild soap and water D. To return on a specific date to have the test results read
Choice C is correct. Systemic lupus erythematosus (SLE) is associated with an elevated risk of lupus nephritis, a severe complication in which the immune system attacks the kidneys. In addition to signs and symptoms associated with SLE, clients with lupus nephritis will often exhibit or report foamy urine (due to the amount of protein in the urine) and possibly hematuria. Once these findings are reported to the nurse, the nurse should perform an additional assessment, assessing the client for possible renal involvement or dysfunction. The nurse should then alert the health care provider (HCP) of these findings and initiate further diagnostic testing as ordered.
A nurse is caring for a 45-year-old client diagnosed with systemic lupus erythematosus (SLE). Which of the following findings would indicate a need for an additional assessment? A. The client complains of difficulty covering up a butterfly rash present on the nose B. The client complaints about the sunlight, requesting unlicensed assistive personnel (UAP) to close all the blinds in the room C. The client reports foamy urine with a slight reddish tint D. The client reports of joint stiffness
Choice A is correct. Drug therapy for systemic lupus erythematosus (SLE) often involves a combination of general immunosuppressant agents and selective immunosuppressive agents, with corticosteroids (i.e., prednisone) remaining a common cornerstone of SLE therapy. Since all immunosuppressants reduce the client's protective immunity to some degree, all SLE clients taking these medications will be at an increased risk for new or additional infections. Therefore, during exacerbations, nursing care should always be directed toward preventing infection(s), as SLE clients are considered immunocompromised not only due to the medications themselves, but also because SLE is an inflammatory disorder of autoimmune etiology. Regardless of the duration the client has been on immunosuppressant therapy, the nurse should focus on preventing new or additional infections when caring for this SLE client.
A nurse is caring for a client with systemic lupus erythematosus (SLE) in the acute exacerbation phase. The nurse should focus on which aspect of nursing care? A. Prevention of new or additional infection(s) B. Alleviate feelings of powerlessness C. Development of positive coping skills D. Provide social support
Verify and confirm that the code strip corresponds to the meter code. Disinfect the client's finger with an alcohol swab. Prick the side of the finger using the lancet. Turn the finger down so the blood will drop with gravity. Wipe off the first drop of blood using sterile gauze. Collect the next drop on the test strip. Hold the gauze on the client's finger after the specimen has been obtained. Read the client's blood glucose level on the monitor.
A nurse is in-training for the correct way to monitor blood glucose levels. Arrange the following steps of the blood glucose monitoring technique in the correct sequence. Collect the next drop on the test strip. Wipe off the first drop of blood using sterile gauze. Prick the side of the finger using the lancet. Hold the gauze on the client's finger after the specimen has been obtained. Read the client's blood glucose level on the monitor. Disinfect the client's finger with an alcohol swab. Turn the finger down so the blood will drop with gravity. Verify and confirm that the code strip corresponds to the meter code.
Choice C is correct. Prednisone, like all glucosteroids, decreases gastrointestinal absorption of calcium, specifically in the intestines. Therefore, in a client with hyperparathyroidism, prednisone may be used to reduce the client's high serum calcium levels (hypercalcemia).
A nurse is preparing to administer prednisone 5 mg orally to a client with primary hyperparathyroidism. The nurse understands that prednisone is given to this client because: A. Prednisone increases the client's immune function B. Prednisone increases the client's vitamin D levels C. Prednisone decreases gastrointestinal absorption of calcium D. Prednisone decreases the release of calcium by the bones
Choice B is correct. Regular insulin is considered a short-acting insulin and will peak two to three hours after subcutaneous administration. Therefore, the peak of this medication would occur between 1000-1100. NPH insulin is considered an intermediate-acting insulin, with a peak of four to 12 hours following administration (i.e., between 1200-2000). Since these insulins are being co-administered, there are two separate times at which the client has the highest risk of becoming hypoglycemic based on the times when both insulins peak, the first of which initially occurs at 1000 (the second peak time beginning at 1200). Therefore, the nurse should initially assess the client for signs and symptoms of hypoglycemia at 1000.
The nurse administers a combination of regular insulin and NPH insulin subcutaneously to a client at 0800. At which time should the nurse initially assess the client for hypoglycemia based on the peaks of the medications? A. 0830 B. 1000 C. 1200 D. 1400
Choices A, B, C, and D are correct. A is correct. In Graves' disease, an overproduction of thyroid hormones (hyperthyroidism) can speed up the body's metabolism, leading to symptoms like increased heart rate and palpitations. B is correct. Hyperthyroidism can increase the speed at which food travels through the digestive tract, resulting in diarrhea or more frequent bowel movements. C is correct. Hyperthyroidism can lead to nervous system hyperactivity, which can cause fine tremors, especially in the hands and fingers. D is correct. Graves' disease can cause Graves' ophthalmopathy, leading to inflammation and other changes in the eye tissues, resulting in bulging eyes or exophthalmos.
The nurse cares for a 38-year-old female client recently diagnosed with Graves' disease. The client presents with a visibly enlarged thyroid gland, heat intolerance, excessive sweating, and unintentional weight loss. What additional signs or symptoms may be present in this client? Select all that apply. Increased heart rate and palpitations Diarrhea and frequent bowel movements Tremors, particularly in the hands and fingers Eye changes such as exophthalmos Intolerance to cold temperatures
Choice B is correct. Here, since the client reports no symptoms and the scenario does not indicate the client is actively experiencing any signs or symptoms of hypoglycemia, the nurse's initial action should be to repeat the capillary blood glucose test to validate the test result. Repeating the capillary blood glucose test will help determine whether the hypoglycemic reading may have resulted from an operator or machine error. Additionally, since the reading provided by the glucometer does not correlate with the objective findings observed by the nurse's assessment of the client, the nurse should validate the result by performing a second capillary blood glucose check. Of note, if the client were symptomatic, the nurse's initial action would not be to repeat the capillary blood glucose test to validate the test result.
The nurse caring for a diabetes mellitus client obtained a scheduled capillary blood glucose. The result indicated 40 mg/dL (2.22 mmol/L). The client reports no symptoms. The initial action of the nurse should be which of the following? A. Document the finding in the medical record B. Repeat the capillary blood glucose test to validate the result C. Administer 15 grams of a quick-acting carbohydrate D. Administer 1 mg of glucagon subcutaneously
Choice A is correct. A common complication associated with SLE is the development of lupus nephritis. Glomerular injury is seen in lupus nephritis because of the significant inflammation caused by this condition. The client with SLE should have routine urine analysis because evidence of lupus nephritis would consist of proteinuria and microscopic hematuria. Other laboratory testing pointing to lupus nephritis would be an elevated creatinine and decreased glomerular filtration rate. Lupus nephritis may be so aggressive that it may cause an individual to need a kidney transplant.
The nurse in the outpatient clinic is assessing a client with systemic lupus erythematosus (SLE). Which laboratory data is essential for the nurse to monitor to determine if the client is experiencing a complication? A. urine analysis B. hemoglobin A1C (HbA1C) C. thyroid-stimulating hormone (TSH) D. ammonia
Choice B is correct. Raynaud phenomena is a condition causing painful vasospasms in response to emotional stress and cold temperatures. These painful vasospasms occur in the digits. Raynaud phenomena may be associated with autoimmune conditions such as systemic lupus erythematosus (SLE) and scleroderma.
The nurse is assessing a client who has suspected Raynaud phenomenon/disease. Which of the following findings would support a diagnosis of Raynaud phenomenon/disease? A. unilateral swelling of the leg B. painful vasospasms C. crepitus of the joints D. claudication in feet and lower extremities
Choice B is correct. an HbA1c level of 7.5%. HbA1c is a level that reflects long-term glucose control, and a level of 7.5% is consistent with a diagnosis of diabetes mellitus type 2. 5.7-6.4% Prediabetes 6.5% Diabetes Mellitus Dx < 7% treatment goal for those with diabetes mellitus
The nurse is assessing a client with diabetes mellitus type 2. Which of the following findings would be consistent with a diagnosis of diabetes mellitus type 2? A. Fasting blood glucose level 110 mg/dL (6.1 mmol/L [70-110 mg/dL (3.9 mmol/L and 5.5 mmol/L)] B. Hemoglobin A1c (HbA1c) level 7.5% [< 5.7%] C. Elevated Serum Insulin Levels D. Presence of ketones in the urine
Choice A is correct. Hyperparathyroidism causes a client to develop hypercalcemia. While most clients are asymptomatic, clients may go on to develop manifestations such as nephrolithiasis, polyuria, confusion, constipation, and shortened QT interval. The client with hyperparathyroidism would cause the client to develop hypercalcemia, which increases the client's proclivity to develop nephrolithiasis. The reason for nephrolithiasis is that the urinary calcium levels are high, which makes conditions favorable for storm formation.
The nurse is assessing a client with hyperparathyroidism. Which of the following findings would support a diagnosis of hyperparathyroidism? A. nephrolithiasis B. hyperphosphatemia C. diarrhea D. halitosis
Choices A, B, D, and E are correct. Hypothyroidism causes an overall slowing of metabolic processes that contribute to patients developing constipation, fatigue, weight gain, bradycardia, periorbital edema, and decreased libido.
The nurse is assessing a client with hypothyroidism. Which of the following assessment findings would be expected? Select all that apply. Decreased libido Bradycardia Heat intolerance Fatigue Constipation
Choice B is correct. Dilutional hyponatremia may occur from SIADH from the excess water caused by the antidiuretic hormone. The hyponatremia may be so severe that it may cause neuromuscular weakness and seizure activity. Sodium levels should be trended carefully during the course of the illness.
The nurse is assessing a patient with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory tests require careful monitoring? A. Potassium B. Sodium C. Glucose D. Magnesium
Choice B is correct. Clients with Raynaud's disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction. The nurse should question the physician regarding this prescription.
The nurse is caring for a client with Raynaud's disease who has just been prescribed ephedrine. What is the nurse's most appropriate action? A. Provide dietary instructions to the client. B. Question and discuss the prescription with the physician. C. Instruct the client regarding adverse effects. D. Administer the medication initially to the client.
Choice B is correct. Cushing's syndrome is characterized by chronic exposure to a glucocorticoid. This is oftentimes referred to as secondary Cushing's syndrome. This client has been on a steroid for two years, and considering the long duration, this client is at the highest risk of developing this syndrome.
The nurse is assessing clients for the risk of developing Cushing's syndrome. The nurse should identify which client is at greatest risk for this syndrome? A client A. recently diagnosed with hyperpituitarism and high blood pressure. B. who has been taking prednisone for 2 years to treat rheumatoid arthritis (RA). C. who has a goiter, and is receiving propranolol and propylthiouracil (PTU). D. experiencing eczema and is prescribed a seven-day course of topical hydrocortisone.
Choice B is correct. Hypothyroidism causes a decreased metabolic demand, so fewer calories are required. The basal metabolic rate (BMR) is the rate of energy expenditure at rest in a neutral environment after the digestive system has been inactive for about 12 hours. This basal metabolism refers to energy spent for the normal functioning of the brain and central nervous system, heart, kidneys, liver, lungs, muscles, sex organs, and skin. The BMR accounts for approximately 60% of the daily energy expenditure. Patients with hypothyroidism have a low basal metabolic rate and hence, a positive nitrogen balance. Some clinical manifestations of hypothyroidism include weight gain, decreased appetite, constipation, reduced heart rate, cold intolerance, hyperglycemia, and dyslipidemia. Severe cases are characterized by myxedema coma.
The nurse is attending to a client with recent significant weight gain. Which of the following diseases decrease the basal metabolic rate? A. Cancer B. Hypothyroidism C. Chronic obstructive pulmonary disease (COPD) D. Cardiac failure
Choice B is correct. A client with Cushing's disease has too many steroids and will have manifestations such as central obesity, weight gain, hypokalemia, hypernatremia, and hypertension. The client will not need more steroids during periods of stress as this is necessary for a patient with Addison's disease to prevent a crisis.
The nurse is caring for a client newly diagnosed with Cushing's disease. Which of the following client statements requires follow-up? A. "I will need to eat more potassium-rich foods." B. "I will need more steroids during periods of stress." C. "I will be at a higher risk for an infection." D. "I should do weight-bearing exercises."
Choice D is correct. Recognizing the signs and symptoms of hypoglycemia is essential since hypoglycemia can be lethal. Signs and symptoms of hypoglycemia include palpitations, tachycardia, cool and clammy skin, lethargy, and coma.
The nurse is caring for a client newly diagnosed with type I diabetes mellitus. It would be essential to educate the client to A. check their hemoglobin A1C level every three months. B. rotate injection sites for insulin administration. C. examine their feet with a mirror daily. D. recognize the symptoms of hypoglycemia.
Choices A and B are correct. Hourly glucose and potassium are essential labs to be monitored while a client receives a continuous infusion of regular insulin. Potassium levels need to be monitored while a client is receiving regular insulin because it pushes potassium back into the cell, and this shift causes hypokalemia. Hourly glucose is essential to monitor as it may cause a client to develop life-threatening hypoglycemia.
The nurse is caring for a client receiving a continuous infusion of regular insulin. The nurse should plan to monitor which clinical data? Select all that apply. Hourly blood glucose Potassium BUN and creatinine Gastric pH Fasting blood glucose
Choice C is correct. Vital signs are the most critical priority in the pre-operative period. A client with pheochromocytoma has a high risk of developing a hypertensive emergency and cardiac dysrhythmias because of the increased catecholamine levels. Antihypertensive medications are commonly prescribed to prevent a hypertensive crisis.
The nurse is caring for a client scheduled for an adrenalectomy after being diagnosed with pheochromocytoma. Which preoperative clinical data is essential for the nurse to monitor? A. intake and output B. blood glucose C. vital signs D. hemoglobin and hematocrit
Choice D is correct. A thyroid storm is a medical emergency and is a complication of hyperthyroidism. Manifestations of a thyroid storm include fever, tachycardia, hypertension, and cardiac dysrhythmias. Emergent treatments for a thyroid storm include prescribed dexamethasone (corticosteroids inhibit the peripheral conversion of T4 into T3), propranolol (to reduce heart rate and blood pressure), and an antithyroid medication such as propylthiouracil.
The nurse is caring for a client who developed a thyroid storm. The nurse should obtain a prescription for A. enalapril B. regular insulin C. levothyroxine D. dexamethasone
Choice D is correct. The treatment goal for a client with diabetes mellitus is to minimize episodes of hyperglycemia which will then, in turn, reduce the hemoglobin A1C. The treatment goal for a client with diabetes mellitus is to keep the A1C less than 7%.
The nurse is caring for a client who has diabetes mellitus. Which of the following would indicate the client is achieving the treatment goals? A. Fasting blood glucose 145 mg/dl B. Creatinine 2.3 mg/dl C. Urine Specific Gravity 1.043 D. Hemoglobin A1C 6.7%
Choice A is correct. For a client with DKA, hypovolemia and hyperglycemia are the primary problems. Hyperglycemia contributes to acidosis and hypovolemia. A normal MAP would indicate effective tissue perfusion and, thus, would be a favorable finding indicating that the hypovolemia has resolved. Normal MAP is between 70 and 100 mm Hg.
The nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following would indicate the client is achieving the treatment goals? A. Mean arterial pressure (MAP) 71 mmHg B. Potassium 3.3 mEq/L C. Blood glucose 255 mg/dL D. Serum pH 7.33
Choices A and B are correct. Following a parathyroidectomy, aggressive calcium replacement typically commences. Two medications commonly prescribed include cholecalciferol (Vitamin D3) and calcium carbonate. Cholecalciferol is necessary to enhance the absorption of calcium carbonate. Calcium levels are monitored closely following this procedure. The parathyroid regulates calcium via the release of parathyroid hormone.
The nurse is caring for a client who recently had a total parathyroidectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order? Select all that apply Calcium carbonate Cholecalciferol Calcitonin Folic acid Magnesium oxide
Choice B is correct. Regular insulin can cause hypokalemia. While a client receives treatment for diabetic ketoacidosis (DKA) with regular insulin, the nurse should continually monitor potassium and glucose as the insulin will lower both.
The nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving an infusion of regular insulin. Which of the following clinical data should be reported to the primary healthcare provider (PHCP) immediately? A. Glucose 297 mg/dL B. Potassium 3.2 mEq/L C. BUN 24 mg/dL D. Hemoglobin A1C 8.9%
Choice A is correct. Hyponatremia is a classic clinical feature associated with the syndrome of inappropriate antidiuretic hormone (SIADH). The hyponatremia may become severe and cause the client to have an altered mental status (AMS). This AMS is concerning because this signals that the serum sodium is quite low and warrants immediate intervention.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate follow-up? A. Disorientation B. High urine specific gravity C. Oliguria D. Increased thirst
Choice A is correct. For a client with the dawn phenomenon, it would be expected that the client has morning hyperglycemia caused by the release of various hormones (cortisol, growth hormone, and adrenaline).
The nurse is caring for a client with type 1 diabetes mellitus who develops hyperglycemia between 5:00 and 6:00 AM as a result of the nighttime release of growth hormone. The nurse should recognize that this condition is consistent with A. dawn phenomenon. B. Somogyi effect. C. hyperosmolar hyperglycemic syndrome (HHS). D. diabetic ketoacidosis (DKA).
Choices A and E are correct. A client with diabetic ketoacidosis (DKA) receiving regular insulin intravenously is at significant risk for hypoglycemia because regular insulin (given intravenously) peaks within fifteen to thirty minutes. This is why the client has their glucose taken every hour. Lispro insulin is a rapid-acting insulin, and if the client has not eaten within ten to fifteen minutes of getting the insulin, they run the risk of hypoglycemia.
The nurse is caring for assigned clients. The nurse should recognize which client is at risk of developing hypoglycemia? Select all that apply. A client with diabetic ketoacidosis receiving continuous regular insulin intravenously. receiving methylprednisolone for an exacerbation of asthma. with pancreatitis and is receiving total parenteral nutrition (TPN). who is nothing by mouth (NPO) status following a coronary artery bypass graft (CABG). who received six units of lispro insulin one hour ago and has not eaten.
Choices B, C, and D are correct. Many elderly clients suffer from chronic pain ( for example; arthritic pain). Chronic pain and continuous stress can negatively affect the immune system. Uncontrolled and persistent pain can trigger a stress response. Stress is associated with an increase in cortisol. Chronic cortisol elevation causes reduced immune response. Therefore, the nurse should discuss the strategies to manage pain and stress appropriately. Additionally, the nurse should also educate the elderly clients to maintain a well-balanced diet to promote a healthy immune system
The nurse is caring for several geriatric clients. Which of the following should the nurse include in the teaching plan for older clients with altered immune responses? Select all that apply. It is normal to run a slightly higher than normal temperature. If arthritis pain begins to bother you, the doctor can prescribe something for pain. I'd like to talk to you about ways to manage stress. It is very important to eat a well-balanced diet. Don't worry about coming in for routine vaccinations
Choice D is correct. This client demonstrates hypothyroidism manifestations because decreased thyroid functioning causes weight gain, periorbital edema, and decreased motivation (avolition). All three clinical features are directly linked to hypothyroidism. This client is at the greatest risk because all of their manifestations are strongly associated with hypothyroidism.
The nurse is conducting health screenings for hypothyroidism at the community health fair. Which client is at the highest risk for this condition? A client who is A. is underweight, anxious, has a rapid pulse and reports persistent diarrhea. B. is overweight, reports perspiration while playing sports, and reports feeling cold all the time. C. is obese, has high blood pressure, and has frequent reports of thirst. D. is obese, has periorbital edema, and reports a decrease in motivation.
Choices B, D, and E are correct. These statements are incorrect and require follow-up. Pheochromocytoma is a rare tumor that sits on top of the adrenal medulla. This causes an increase in the discharge of catecholamines, causing hypertension, headache, and hyperglycemia. This condition would not cause a decrease in glucose. The client should abstain from energy drinks and caffeine because they can elevate blood pressure further. Diuretics are not used to manage this condition because fluid retention is not a clinical finding associated with this disorder. Alpha-adrenergic blockers are the treatment of choice, followed by surgery.
The nurse is creating a teaching plan for a client diagnosed with pheochromocytoma. Which statement, if made by the client, would require follow-up? Select all that apply. "It will be very important to reduce the stress in my life." "This condition may cause my glucose to decrease." "I will need to monitor my blood pressure closely." "If I feel tired, it is okay for me to have an energy drink." "Diuretics will be prescribed to help eliminate the fluid I may retain."
Choice D is correct. Grave's disease is the most common form of hyperthyroidism. A significant complication of this condition is the potential for a thyroid storm. A thyroid storm is caused by a surge in thyroid hormone in the bloodstream, which causes the client to experience tachycardia, fever, hypertension, diaphoresis, and tachydysrhythmias.
The nurse is performing discharge teaching for a client with Graves' disease. Which of the following client statements indicates effective understanding? A. "I will take my pulse daily and report a rate less than 60 beats/minute." B. "I am going to add hot yoga to my exercise routine." C. "I will increase the amount of fiber in my diet." D. "I should tell my physician if my blood pressure's top number exceeds 140."
Choices B, C, and E are correct. Addison's disease is a problem dealing with deficient aldosterone and cortisol. Aldosterone is responsible for sodium retention and potassium elimination. A clinical feature of this disorder is insufficient aldosterone, causing the client to experience elevated potassium; thus, continuous cardiac monitoring is warranted. The priority treatment for a client with Addison's is to replace the missing steroid. Thus, hydrocortisone is essential. The nurse should implement fall precautions because, with a low amount of cortisol and aldosterone, the client is at risk for dehydration, leading to orthostatic hypotension.
The nurse is developing a plan of care for a client diagnosed with Addison's disease. Which of the following should the nurse include in the client's plan of care? Select all that apply. Diet high in potassium Continuous telemetry monitoring Intravenous hydrocortisone Fluid restriction Fall precautions Indwelling urinary catheter
Choices A, B, and D are correct. For the client with hypothyroidism, dry skin with thinning hair is common. Applying lotion right after a bath is an effective strategy for moisturizing skin. Constipation is a hallmark finding in hypothyroidism, and the nurse can promote bowel regularity by offering noncaffeinated beverages (caffeine will dehydrate the client) and high-fiber snacks. Frequent physical activities are encouraged because the client with hypothyroidism has weight gain. Physical activity will help with weight reduction, and the movement may also promote bowel regularity. Frequent rest periods should be arranged because of the fatigue associated with the condition.
The nurse is developing a plan of care for a client with hypothyroidism that is not controlled with medication. The nurse should recommend Select all that apply. applying lotion after a warm bath. high-fiber snacks. caffeinated beverages to promote energy. physical activities with frequent rest breaks. adding fans to the room to keep it cool.
Choices A and B are correct. All of these options are functions of the parathyroid hormone. Parathyroid hormone (PTH) is released by the parathyroid located at the bottom of the neck behind the thyroid. PTH causes osteoclastic activity, which causes calcium to be released from the bone to the bloodstream to raise serum calcium levels. PTH further promotes renal tubular reabsorption of calcium.
The nurse is discussing about the functions of the parathyroid hormone (PTH) with a student. Which of the following statements would be correct for the nurse to make? Select all that apply. The parathyroid hormone moves calcium from bones to the bloodstream. promotes renal tubular reabsorption of calcium. controls bodily functions such as metabolism and heart rate. promotes renal tubular reabsorption of phosphorus. causes the retention of sodium and the excretion of potassium.
Choice B and D are correct. Graves' disease may cause a client to develop exophthalmos. Angle-closure glaucoma is a medical emergency where the IOP is greater than 30 mmHg, and the client has manifestations such as eye pain, headache, blurred vision, and reddened eye appearance.
The nurse is discussing ocular disorders with a group of nursing students. Which of the following statements would be correct for the nurse to make? Select all that apply. Cataracts are caused by increased ocular pressure (IOP). Graves' disease may cause exophthalmos. Macular degeneration is manifested by loss of peripheral vision. Angle-closure glaucoma is manifested by headache and eye pain. Hyphema results in increased aqueous humor in the anterior chamber.
Choice A is correct. The client should be instructed to check their feet daily for any signs of blisters, sores, or dryness, which can cause cracking. The earlier the detection of an abnormality, the earlier an intervention can be employed, such as prescribed medicinal creams. Choice B is correct. The client should keep the feet dry, and this will prevent chafing from moisture. Additionally, drying the feet will prevent fungal infections. Choice C is correct. A blister or sore should never be opened. The opening may create a non-healing open wound because the healing time is often delayed.
The nurse is educating a diabetic client regarding foot care. Which of the following statements by the client indicates a correct understanding of the nurse's instructions? Select all that apply. "I need to check my feet daily for sores, blisters, dry skin, and cuts." "I need to wash my feet daily and keep them dry." "If I get sores or blisters on my feet, I should not pop them." "I need to apply cream to my heels and between my toes daily." "I should wear tight compression socks on both feet."
Choices A, B, and E are correct. Glucocorticoids may cause potential mood changes such as overall mood lability. This may encompass a client feeling euphoric, agitated, depressed, and anxious. Exposure to long-term corticosteroids may cause an individual to develop leukopenia which may cause immunosuppression. Weight gain is a common finding with corticosteroid use because of the retention of sodium which causes the body to hold onto water.
The nurse is educating a group of students on the effects of corticosteroids. It would be appropriate for the nurse to identify the following adverse effects associated with corticosteroids. Select all that apply. Mood lability Immunosuppression Hypoglycemia Hyperkalemia Weight gain
Choice D is correct. Cushing's disease produces elevated cortisol levels. Cortisol is best known for helping support the body's natural "fight-or-flight" instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance.
The nurse is educating a new graduate about alterations in cortisol levels. Which of the following conditions does she explain cause an increased cortisol levels in a client? A. Addison's disease B. Congestive heart failure C. Renal failure D. Cushing's disease
The most recent hemoglobin A1C was 7.6%. A weight gain of three kilograms was noted. The client reports a painless ulcer on the right anterior ankle.
The nurse is evaluating the treatment plan for a client with type II diabetes mellitus Nurses' Notes The client presents for a routine follow-up after being diagnosed with diabetes mellitus type II. The most recent hemoglobin A1C was 7.6%. A weight gain of three kilograms was noted. The client reports a painless ulcer on the right anterior ankle. The client stated he stopped walking barefoot. The client requested a referral for a diabetic cooking class.
Choice A is correct. Elderly clients experience an increased autoimmune response that puts them at higher risk for experiencing diseases such as rheumatoid arthritis and other collagen-related diseases.
Which of the following clinical manifestations of the aging immune system should alert the nurse to increased susceptibility to illness in elderly clients? A. Increased autoimmune responses B. Increased production of T and B cells C. Increased lymphoid tissue D. Increased circulation of lymphocytes
Choice A is correct. Anaphylaxis quickly causes a loss of vascular tone resulting in hypotension. Establishing intravenous access is essential as the client will require isotonic fluids to restore circulating volume, corticosteroids, and diphenhydramine. Epinephrine, the priority drug to be administered, should be given intramuscular (IM).
The nurse is planning a staff development conference about anaphylaxis. Which of the following information should the nurse include? A. 0.9% saline should be infused once vascular access is established. B. The initial treatment is intravenous diphenhydramine. C. The client should carry a prefilled syringe of hydrocortisone. D. If shock occurs, the client should be positioned in reverse Trendelenburg.
Choice B is correct. A client with chronic diabetes insipidus (DI) must weigh themselves daily. This weight should be taken with the same scale and obtained after the first-morning void. Weight is the most accurate assessment relevant to fluid volume status.
The nurse is providing discharge instructions to a client who has chronic diabetes insipidus (DI). Which of the following client statements would indicate a correct understanding of the discharge instructions? A. "I will need to drink no more than 800 ml per day." B. "I will need to weigh myself at the same time every day." C. "I should increase salty snacks in my diet." D. "I need to log my daily fluid intake."
Choices A, B, C, and D are correct. Excessive thyroid hormones stimulate most body systems, causing hypermetabolism and increased sympathetic nervous system activity. This gives the client with hyperthyroidism the classic features such as tachycardia, increased body temperature, weight loss, diaphoresis, insomnia, elevated systolic blood pressure, and ocular symptoms such as an injected (reddened) conjunctiva.
The nurse is reviewing endocrine disorders with a group of students. It would be correct for the nurse to identify which manifestation is associated with hyperthyroidism? Select all that apply. Injected (red) conjunctiva Insomnia Increased systolic blood pressure Diaphoresis Confusion
Choice D is correct. A client with hypoparathyroidism is at risk of hypocalcemia and should therefore be on a diet high in calcium and low in phosphorus. The high calcium serves to increase the client's serum calcium levels. Since calcium and phosphorus have an inversely proportional relationship, the low phosphorus portion of this diet ensures that the client's phosphorus levels are reduced to the point of not interfering with the client's calcium levels.
The nurse is reviewing the diet of the client with hypoparathyroidism. The nurse understands that the client should be on what type of diet? A. High-calorie, low-calcium diet B. Low-calcium, low-phosphorus diet C. High-phosphorus, low-calcium diet D. High-calcium, low-phosphorus diet
Choices B, C, and D are correct. The guidelines for treating hypoglycemia adhere to the rule of 15s. The rule of 15s calls for administering 15 grams of quick-acting carbohydrates and rechecking the client's glucose in 15 minutes. These food items contain at least 15 grams of quick-acting carbohydrates. The nurse needs to assess the client, and if the client is passive or unconscious, they should not be given anything by mouth because of the risk of aspiration.
The nurse is teaching a review course on foods appropriate to treat hypoglycemia. It indicates appropriate understanding if an attendee states that which item should be provided? Select all that apply. Slice of chicken breast 1 tablespoon of honey ½ cup of regular soda ½ cup of juice Two hardboiled eggs
Choice D is correct. The hemoglobin A1C value of 6.1% shown is abnormal (normal HgbA1c is below 5.7). Prediabetes is a hemoglobin A1C value from 5.7% to 6.4%. The nurse should educate the client on lifestyle changes such as exercise and consuming foods low in simple carbohydrates. The HgbA1C and fasting blood glucose levels need to be monitored with the goal of both trending downward. If the trend continues, the client risks diabetes mellitus which is diagnosed at a hemoglobin A1C of 6.5% or greater.
The nurse reviews laboratory data for a client with suspected diabetes mellitus (DM). Which action should the nurse take based on the client's hemoglobin A1C? See the image below. A. Assess the client for an infection B. Instruct the client that the results are within normal limits C. Assess the client's urine for glycosuria D. Educate the client on a diet with low glycemic foods
"I will need to weigh myself at the same time every day." "I need to keep a log of my fluid intake and urine output." "I may need an additional dose if I keep urinating a lot." "If I develop confusion with this medication, I should call 911."
Which four (4) client statements would indicate a correct understanding of the teaching? "I should limit the amount of fluids that I drink after 5:00 PM." "I will need to weigh myself at the same time every day." "I should put both doses of the desmopressin in one nostril." "I need to keep a log of my fluid intake and urine output." "I may need an additional dose if I keep urinating a lot." "If I develop confusion with this medication, I should call 911."