DIABETES & THYROID/PARATHYROID
(73) The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? (A) Complaints of extreme fatigue and hair loss. (B) Exophthalmos and complaints of nervousness. (C) Complaints of profuse sweating and flushed skin. (D) Tetany and complaints of stiffness of the hands.
(A) A DECREASE IN THYROID HORMONE CAUSES DECREASED METABOLISM, WHICH LEADS TO FATIGUE AND HAIR LOSS. (B) These are signs of hyperthyroidism. (C) These are signs of hyperthyroidism. (D) These are signs of parathyroidism. (Test-taking hint: Often if the test taker does not know the specific signs/symptoms of the disease, but knows the function of the system affected by the disease, some possible answers can be ruled out. Tetany and stiffness of the hands are related to calcium, the level of which is influenced by the parathyroid gland, not the thyroid gland; therefore, option "4" can be ruled out.)
(20) The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? (A) "When is the last time you took your insulin?" (B) "When did you have your last meal?" (C) "Have you had some type of infection lately?" (D) "How long have you had diabetes?"
(A) A client with type 2 diabetes usually is prescribed oral hypoglycemic medications, not insulin. (B) The client could not eat enough food to cause a 680 mg/dL blood glucose level; therefore, this question does not need to be asked. (C) THE MOST COMMON PRECIPITATING FACTOR IS INFECTION. THE MANIFESTATIONS MAY BE SLOW TO APPEAR, WITH ONSET RANGING FROM 24 HOURS TO 2 WEEKS. (D) This does not help determine the cause of the client's HHNS. (Test-taking hint: If the test taker does not know the answer to this question, the test taker could possibly relate to the phrase "acute complication" and realize a medical problem might cause this and select infection, option "3.")
(7) The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? (A) Assess the client's ability to read small print. (B) Monitor the client's serum PT level. (C) Teach the client how to perform a hemoglobin A1c test daily. (D) Instruct the client to check the feet weekly.
(A) AGE-RELATED VISUAL CHANGES AND DIABETIC RETINOPATHY COULD CAUSE THE CLIENT TO HAVE DIFFICULTY IN READING AND DRAWING UP INSULIN DOSAGE ACCURATELY. (B) The PT level is monitored for clients receiving Coumadin, an anticoagulant, which is not ordered for client with diabetes, type 1 or 2. (C) Glycosylated hemoglobin is a serum blood test usually performed in a laboratory, not in the client's home. The hemoglobin A1c is performed every 3 months. Self-monitoring blood glucose (SMBG) should be taught to the client. (D) The client's feet should be checked daily, not weekly. In a week the client could have developing gangrene from an injury the client did not realize he or she had. (Test-taking hint: Always notice the age of a client if it is provided because this is important when determining the correct answer for the question. Be sure to note the adverbs, such as "weekly" instead of "daily.")
(6) The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? (A) The client has crumbling toenails. (B) The client has athlete's foot. (C) The client has a necrotic big toe. (D) The client has thickened toenails.
(A) Crumbling toenails indicate tinea unguium, which is a fungus infection of the toenail. (B) Athlete's foot is a non-life-threatening fungal infection. (C) A NECROTIC BIG TOE INDICATES "DEAD" TISSUE. THE CLIENT DOES NOT FEEL PAIN, DOES NOT REALIZE THE INJURY, AND DOES NOT SEEK TREATMENT. INCREASED BLOOD GLUCOSE LEVELS DECREASE THE OXYGEN SUPPLY NEEDED TO HEAL THE WOUND AND INCREASE THE RISK FOR DEVELOPING AN INFECTION. (D) Big, thick toenails are fungal infections and do not require immediate intervention by the nurse. (Test-taking hint: The test taker should select the option indicating this is possibly a life-threatening complication or some type of assessment data the healthcare provider should be informed of immediately. Remember "warrants immediate intervention.")
(79) Which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism? (A) "I just don't seem to have any appetite anymore." (B) "I have a bowel movement about every 3-4 days." (C) "My skin is really becoming dry and coarse." (D) "I have noticed all my collars are getting tighter."
(A) Decreased appetite is a symptoms of hypothryoidism, not hyperthyroidism. (B) Constipation is a symptom of hypothyroidism. (C) Dry, coarse skin is a sign of hypothyroidism. (D) THE THYROID GLAND (IN THE NECK) ENLARGES AS A RESULT OF THE INCREASED NEED FOR THYROID HORMONE PRODUCTION; AN ENLARGED GLAND IS CALLED A GOITER. (Test-taking hint: If the test taker does not know the answer, sometimes thinking about the location of the gland or organ causing the problem may help the test taker select or rule out specific options.)
(74) The nurse identifies the client problem "risk for imbalanced body temperature" for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care? (A) Discourage the use of an electric blanket. (B) Assess the client's temperature every 2 hours. (C) Keep the room temperature cool. (D) Space activities to promote rest.
(A) EXTERNAL HEAT SOURCES (HEATING PADS, ELECTRIC OR WARMING BLANKETS) SHOULD BE DISCOURAGED BECAUSE THEY INCREASE THE RISK OF PERIPHERAL VASODILATION AND VASCULAR COLLAPSE. (B) Assessing the client's temperature every 2 hours is not needed because the temperature will not change quickly. The client needs thyroid hormones to help increase the client's temperature. (C) The room temperature should be kept warm because the client will have complaints of being cold. (D) The client is fatigued and this is an appropriate intervention, but is not applicable to the client problem of "risk for imbalanced body temperature." (Test-taking hint: The test taker must always know exactly what the question is asking. Option "4" can be ruled out because it does not address body temperature. If the test taker knows the normal function of the thyroid gland, this may help identify the answer; decreased metabolism will cause the client to be cold.)
(76) Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? (A) Increase the amount of fiber in the diet. (B) Encourage a low-calorie, low-protein diet. (C) Decrease the client's fluid intake to 1000 ml/day. (D) Provide 6 small, well-balanced meals a day.
(A) Fiber should be increased in the client diagnosed with hypothyroidism because the client experiences constipation secondary to decreased metabolism. (B) The client with hyperthyroidism should have a high-calorie, high-protein diet. (C) The client's fluid intake should be increased to replace fluids lost through diarrhea and excessive sweating. (D) THE CLIENT WITH HYPERTHYROIDISM HAS AN INCREASED APPETITE; THEREFORE, WELL-BALANCED MEALS SERVED SEVERAL TIMES THROUGHOUT THE DAY WILL HELP WITH THE CLIENT'S CONSTANT HUNGER. (Test-taking hint: If the test taker knows the metabolism is increased with hyperthyroidism, then increasing the food intake is the most appropriate choice.)
(15) Which electrolyte replacement should the nurse anticipate being ordered by the healthcare provider in the client diagnosed with DKA who has just been admitted to the ICU? (A) Glucose. (B) Potassium. (C) Calcium. (D) Sodium.
(A) Glucose is elevated in DKA; therefore, the HCP would not be replacing glucose. (B) THE CLIENT IN DKA LOSES POTASSIUM FROM INCREASED URINARY OUTPUT, ACIDOSIS, CATABOLIC STATE, AND VOMITING. REPLACEMENT IS ESSENTIAL FOR PREVENTING CARDIAC DYSRHYTHMIAS SECONDARY TO HYPOKALEMIA. (C) Calcium is not affected in the client with DKA. (D) The prescribed IV for DKA - 0.9% normal saline - has sodium, but it is not specifically ordered for sodium replacement. This is an isotonic solution. (Test-taking hint: Option "1" should be eliminated because the problem with DKA is elevated glucose, so the HCP would not be replacing it. The test taker should use physiology knowledge and realize potassium is in the cell.)
(3) The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? (A) Ensure the client eats the bedtime snack. (B) Determine how much food the client ate at lunch. (C) Perform a glucometer reading at 0700. (D) Offer the client protein after administering insulin.
(A) HUMULIN N PEAKS IN 6-8 HOURS, MAKING THE CLIENT AT RISK FOR HYPOGLYCEMIA AROUND MIDNIGHT, WHICH IS WHY THE CLIENT SHOULD RECEIVE A BEDTIME SNACK. THIS SNACK WILL PREVENT NIGHTTIME HYPOGLYCEMIA. (B) The food intake at lunch will not affect the client's blood glucose level at midnight. (C) The client's glucometer reading should be done around 2100 to assess the effectiveness of insulin at 1600. (D) Onset of Humulin D, an intermediate-acting insulin, is 2-4 hours but it does not peak until 6-8 hours. (Test-taking hint: Remember to look at the adjective or descriptor. Intermediate-acting insulin provides the reader a clue: anything with intermediate action, instead of longer acting, is incorrect.)
(8) The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? (A) Provide a high-fat diet 24 hours prior to test. (B) Hold the biguanide medication for 48 hours prior to test. (C) Obtain an informed consent form for the test. (D) Administer pancreatic enzymes prior to the test.
(A) High-fat diets are not recommended for clients diagnosed with diabetes, and food does not have an effect on a CT scan with contrast. (B) BIGUANIDE MEDICATION MUST BE HELD FOR A TEST WITH CONTRAST MEDIUM BECAUSE IT INCREASES THE RISK OF LACTIC ACIDOSIS, WHICH LEADS TO RENAL PROBLEMS. (C) Informed consent is not required for a CT scan. The admission consent covers routine diagnostic procedures. (D) Pancreatic enzymes are administered when the pancreas cannot produce amylase and lipase, not when the beta cells cannot produce insulin. (Test-taking hint: The test taker could eliminate option "1" because high-fat diets are not recommended for any client. Because the stem specifically refers to the biguanide medication and CT constrast, a good choice addresses both of these. Option "2" discusses both the medication and the test.)
(77) The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse? (A) Serum blood glucose level of 74 mg/dL. (B) Pulse oximeter reading of 90%. (C) Telemetry reading showing sinus bradycardia. (D) The client is lethargic and sleeps all the time.
(A) Hypoglycemia is expected in a client with myxedema; therefore, a 74 mg/dL blood glucose level is expected. (B) A PULSE OXIMETER READING OF LESS THAN 93% IS SIGNIFICANT. A 90% PULSE OXIMETER READING INDICATES A PAO2 OF APPROXIMATELY 60 ON AN ARTERIAL BLOOD GAS TEST; THIS IS SEVERE HYPOXEMIA AND REQUIRES IMMEDIATE INTERVENTION. (C) The client with myxedema coma is in an exaggerated hypothyroid state; a low pulse is expected in a client with hypothyroidism. (D) Lethargy is an expected symptom in client diagnosed with myxedema; therefore, this does not warrant immediate intervention. (Test-taking hint: The words "warrant immediate intervention" means the test taker should select an option which is abnormal for the disease process or a life-threatening symptom.)
(13) The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? (A) Kussmaul's respirations. (B) Diarrhea and epigastric pain. (C) Dry mucous membranes. (D) Ketone breath odor.
(A) Kussmaul's respirations occur with diabetic ketoacidosis (DKA) as a result of the breakdown of fat, resulting in ketones. (B) Diarrhea and epigastric pain are not associated with HHNS. (C) DRY MUCOUS MEMBRANES ARE A RESULT OF THE HYPERGLYCEMIA AND OCCUR WITH BOTH HHNS AND DKA. (D) This occurs wth DKA as a result of the breakdown of fat, resulting in ketones. (Test-taking hint: The test taker must be able to differentiate between HHNS (type 2 diabetes) and DKA (type 1 diabetes), which primarily is the result of the breakdown of fat and results in an increase in ketones causing a decrease in pH, resulting in metabolic acidosis.)
(80) The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client? (A) Explain it will take up to a month for symptoms of hyperthyroidism to subside. (B) Teach the iodine therapy will have to be tapered slowly over 1 week. (C) Discuss the client will have to be hospitalized during the radioactive therapy. (D) Inform the client after therapy the client will not have to take any medication.
(A) RADIOACTIVE IODINE THERAPY IS USED TO DESTROY THE OVERACTIVE THYROID CELLS. AFTER TREATMENT, THE CLIENT IS FOLLOWED CLOSELY FOR 3-4 WEEKS UNTIL THE EUTHYROID STATE IS REACHED. (B) A single dose of radioactive iodine therapy is administered; the dosage is based on the client's weight. (C) The colorless, tasteless radioiodine is administered by the radiologist, and the client may have to stay up to 2 hours after the treatment in the office. (D) If too much of the thyroid gland is destroyed by the radioactive iodine therapy, the client may develop hypothyroidism and have to take thyroid hormone the rest of his or her life. (Test-taking hint: Some questions require the test taker to be knowledgeable of the information, especially medical treatments, and there are no specific hints to help the test taker answer the question.)
(14) The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? (A) Infuse 0.9% normal saline intravenously. (B) Administer intermediate-acting insulin. (C) Perform blood glucometer checks daily. (D) Monitor arterial blood gas results.
(A) THE INITIAL FLUID REPLACEMENT IS 0.9% NORMAL SALINE (AN ISOTONIC SOLUTION) INTRAVENOUSLY, FOLLOWED BY 0.45% SALINE. THE RATE DEPENDS ON THE CLIENT'S FLUID VOLUME STATUS AND PHYSICAL HEALTH, ESPECIALLY OF THE HEART. (B) Regular insulin, not intermediate, is the insulin of choice because of its quick onset and peak in 2-4 hours. (C) Blood glucometer checks are done every 1 hour or more often in clients with HHNS who are receiving regular insulin drops. (D) Arterial blood gases are not affected in HHNS because there is no breakdown of fat resulting in ketones leading to metabolic acidosis. (Test-taking hint: The test taker should eliminate option "3" based on the word "daily." In the ICU with a client who is very ill, most checks are more often than daily. Remember to look at adjectives; "intermediate" in option "2" is the word eliminating this as a possible correct answer.)
(9) The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. (A) Take diabetic medication even if unable to eat the client's normal diabetic diet. (B) If unable to eat, drink liquids equal to the client's normal caloric intake. (C) It is not necessary to notify the healthcare provider if ketones are in the urine. (D) Test blood glucose levels and test urine ketones once a day and keep a record. (E) Call the healthcare provider if glucose levels are higher than 180 mg/dL.
(A) THE MOST IMPORTANT ISSUE TO TEACH CLIENTS IS TO TAKE INSULIN EVEN IF THEY ARE UNABLE TO EAT. GLUCOSE LEVELS ARE INCREASED WITH ILLNESS AND STRESS. (B) THE CLIENT SHOULD DRINK LIQUIDS SUCH AS REGULAR COLA OR ORANGE JUICE, OR EAT REGULAR GELATIN, WHICH PROVIDE ENOUGH GLUCOSE TO PREVENT HYPOGLYCEMIA WHEN RECEIVING INSULIN. (C) Ketones indicate a breakdown of fat and must be reported to the HCP because they can lead to metabolic acidosis. (D) Blood glucose levels and ketones must be checked every 3-4 hours, not daily. (E) THE HCP SHOULD BE NOTIFIED IF THE BLOOD GLUCOSE LEVEL IS THIS HIGH. REGULAR INSULIN MAY NEED TO BE PRESCRIBED TO KEEP THE BLOOD GLUCOSE LEVEL WITHIN ACCEPTABLE RANGE. (Test-taking hint: This is an alternate-type question having more than one correct answer. The test taker should read all options and determine if each is an appropriate intervention.)
(24) The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. (A) Maintain adequate ventilation. (B) Assess fluid volume status. (C) Administer intravenous potassium. (D) Check for urinary ketones. (E) Monitor intake and output.
(A) THE NURSE SHOULD ALWAYS ADDRESS THE AIRWAY WHEN A CLIENT IS SERIOUSLY ILL. (B) THE CLIENT MUST BE ASSESSED FOR FLUID VOLUME DEFICIT AND THEN FOR FLUID VOLUME EXCESS AFTER FLUID REPLACEMENT IS STARTED. (C) THE ELECTROLYTE IMBALANCE OF PRIMARY CONCERN IS DEPLETION OF POTASSIUM. (D) KETONES ARE EXCRETED IN THE URINE; LEVELS ARE DOCUMENTED FROM NEGATIVE TO LARGE AMOUNT. KETONES SHOULD BE MONITORED FREQUENTLY. (E) THE NURSE MUST ENSURE THE CLIENT'S FLUID INTAKE AND OUTPUT ARE EQUAL. (Test-taking hint: The test taker must select all answer options that apply. Do not try to outguess the item writer. In some instances all options are correct.)
(17) The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? (A) Administer 50% dextrose IVP. (B) Notify the healthcare provider. (C) Move the client to the ICU. (D) Check the serum glucose level.
(A) THE NURSE SHOULD ASSUME THE CLIENT IS HYPOGLYCEMIC AND ADMINISTER IVP DEXTROSE, WHICH WILL ROUSE THE CLIENT IMMEDIATELY. IF THE COLLAPSE IS THE RESULT OF HYPERGLYCEMIA, THIS ADDITIONAL DEXTROSE WILL NOT FURTHER INJURE THE CLIENT. (B) The healthcare provider may or may not need to be notified, but this is not the first intervention. (C) The client should be left in the client's room, and 50% dextrose should be administered first. (D) The serum glucose level requires a venipuncture, which will take too long. A blood glucometer reading may be obtained, but the nurse should first treat the client, not the machine. The glucometer only reads "low" after a certain point, and a serum level is needed to confirm exact glucose level. (Test-taking hint: The question is requesting the test taker to select which intervention should be implemented first. All 4 options could be possible interventions, but only 1 intervention should be implemented first. The test taker should select the intervention directly treating the client' do not select a diagnostic test.)
(12) The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? (A) The client will have a blood glucose level between 90 and 140 mg/dL. (B) The client will demonstrate appropriate insulin injection technique. (C) The nurse will monitor the client's blood glucose levels 4 times a day. (D) The client will maintain normal kidney function with 30 mL/hr urine output.
(A) THE SHORT-TERM GOAL MUST ADDRESS THE RESPONSE PART OF THE NURSING DIAGNOSIS, WHICH IS "HIGH RISK FOR HYPERGLYCEMIA," AND THIS BLOOD GLUCOSE LEVEL IS WITHIN ACCEPTABLE RANGES FOR A CLIENT WHO IS NONCOMPLIANT. (B) This is an appropriate goal for a knowledge-deficit nursing diagnosis. Noncompliance is not always the result of knowledge deficit. (C) The nurse is implementing an intervention, and the question asks for a goal which addresses the problem of "high risk for hyperglycemia." (D) The question asks for a short-term goal. (Test-taking hint: Remember the nursing diagnosis consists of a problem related to an etiology. The goals must address the problem and the interventions must address the etiology. The test taker should always remember a short-term goal is usually a goal met during the hospitalization, and the long-term goal may take weeks, months, or even year.)
(23) Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? (A) pH 7.34, PaO2 99, PaCO2 48, HCO3 24. (B) pH 7.38, PaO2 95, PaCO2 40, HCO3 22. (C) pH 7.46, PaO2 85, PaCO2 30, HCO3 26. (D) pH 7.30, PaO2 90, PaCO2 30, HCO3 18.
(A) The ABG indicates respiratory acidosis, which is not expected. (B)This ABG is normal, which is not expected. (C) This ABG indicates respiratory alkalosis, which is not expected. (D) THIS ABG INDICATES METABOLIC ACIDOSIS, WHICH IS EXPECTED IN A CLIENT DIAGNOSED WITH DIABETIC KETOACIDOSIS. (Test-taking hint: The client must know ABGs to be able to correctly answer this question. Normal ABGs are pH 7.35-7.45; PaO2 80-100; PaCO2 35-45; HCO3 22-26.)
(21) The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? (A) Refer the client to the American Diabetes Association. (B) Do not take any over-the-counter medications. (C) Take the prescribed insulin even when unable to eat because of illness. (D) Explain the need to get the annual flu and pneumonia vaccines.
(A) The American Diabetes Association is an excellent referral, but the nurse should discuss specific ways to prevent DKA. (B) The client should be careful with OTC medications, but this intervention does not help prevent the development of DKA. (C) ILLNESS INCREASES BLOOD GLUCOSE LEVELS; THEREFORE, THE CLIENT MUST TAKE INSULIN AND CONSUME HIGH-CARBOHYDRATE FOODS SUCH AS REGULAR JELL-O, REGULAR POPSICLES, AND ORANGE JUICE. (D) Vaccines are important to help prevent illness, but regardless of whether the client gets these vaccines, the client can still develop diabetic ketoacidosis. (Test-taking hint: The words "most important" in the stem of the question indicate 1 or more option may be appropriate instructions but only 1 is the priority intervention.)
(2) The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? (A) This result is below normal levels. (B) This result is within acceptable levels. (C) This result is above recommended levels. (D) The result is dangerously high.
(A) The acceptable level for an A1c for a client with diabetes is between 6% and 7%, which corresponds to a 120- to 140-mg/dL average blood glucose level. (B) This result is not within acceptable levels for the client with diabetes, which is 6% and 7%. (C) THIS RESULT PARALLELS A SERUM BLOOD GLUCOSE LEVEL OF APPROXIMATELY 180 AND 200 MG/DL. AN A1C IS A BLOOD TEST REFLECTING AVERAGE BLOOD GLUCOSE LEVELS OVER A PERIOD OF 3 MONTHS; CLIENTS WITH ELEVATED BLOOD GLUCOSE LEVELS ARE AT RISK FOR DEVELOPING LONG-TERM COMPLICATIONS. (D) An A1c of 13% is dangerously high; it reflects a 300 mg/dL average blood glucose level over the past 3 months. (Test-taking unit: The test taker must know normal and abnormal diagnostic laboratory values. Laboratory values vary depending on which laboratory performs the test.
(10) The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? (A) Instruct the UAP to obtain the blood glucose level. (B) Have the client drink 8 ounces of orange juice. (C) Go to the client's room and assess the client for hypoglycemia. (D) Prepare to administer 1 ampule 50% dextrose intravenously.
(A) The blood glucose level should be obtained, but it is not the first intervention. (B) If it is determined the client is having a hypoglycemic reaction, orange juice is appropriate. (C) REGULAR INSULIN PEAKS IN 2-4 HOURS. THEREFORE, THE NURSE SHOULD THINK ABOUT THE POSSIBILITY THE CLIENT IS HAVING A HYPOGLYCEMIC REACTION AND SHOULD ASSESS THE CLIENT. THE NURSE SHOULD NOT DELEGATE NURSING TASKS TO A UAP IF THE CLIENT IS UNSTABLE. (D) Dextrose 50% is only administered if the client is unconscious and the nurse suspects hypoglycemia. (Test-taking hint: When answering a question requiring the nurse to decide which intervention to implement first, all 4 options are plausible for the situation but only one answer should be implemented first. The test taker must apply the nursing process; assessment is the first step of the nursing process.)
(5) The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? (A) Eat a simple carbohydrate snack before exercising. (B) Carry peanut butter crackers when exercising. (C) Encourage the client to walk 20 minutes 3 times a week. (D) Perform warmup and cool-down exercises.
(A) The client diagnosed with type 2 diabetes who is not taking insulin or oral agents does not need extra food before exercise. (B) The client with diabetes who is at risk for hypoglycemia when exercising should carry a simple carbohydrate, but this client is not at risk for hypoglycemia. (C) Clients with diabetes controlled by diet and exercise must exercise daily at the same time and in the same amount to control the glucose level. (D) ALL CLIENTS WHO EXERCISE SHOULD PERFORM WARMUP AND COOL DOWN EXERCISES TO HELP PREVENT MUSCLE STRAIN AND INJURY, (Test-taking hint: Options "1" and "2" apply directly to clients diagnosed with diabetes and options "3" and "4" do not directly address clients diagnosed with diabetes. The reader could narrow the choices by either eliminating or including the two similar options.)
(19) The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? (A) Instruct the UAP to get the client additional food. (B) Notify the dietitian about the client's request. (C) Request the HCP increase the client's caloric intake. (D) Tell the UAP the client cannot have anything else.
(A) The client is on a special diet and should not have any additional food. (B) THE CLIENT WILL NOT BE COMPLIANT WITH THE DIET IF HE OR SHE IS STILL HUNGRY. THEREFORE, THE NURSE SHOULD REQUEST THE DIETITIAN TALK TO THE CLIENT TO TRY TO ADJUST THE MEALS SO THE CLIENT WILL ADHERE TO THE DIET. (C) The nurse does not need to notify the HCP for an increase in caloric intake. The appropriate referral is to the dietitian. (D) The client is on a special diet. The nurse needs to help the client maintain compliance with the medical treatment and should refer the client to the dietitian. (Test-taking hint: The test taker should select the option attempting to ensure the client maintains compliance. The test taker should remember to work with members of the multidisciplinary healthcare team.)
(75) The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? (A) The client has a 3 lb weight gain. (B) The client has a decreased pulse rate. (C) The client's temperature is WNL. (D) The client denies any diaphoresis.
(A) The medication will help increase the client's metabolic rate. A weight gain indicates not enough medication is being taken to put the client in a euthyroid (normal thyroid) state. (B) A decreased pulse rate indicates there is not enough thyroid hormone level; therefore, the medication is not effective. (C) THE CLIENT WITH HYPOTHYROIDISM FREQUENTLY HAS A SUBNORMAL TEMPERATURE, SO A TEMPERATURE WNL INDICATES THE MEDICATION IS EFFECTIVE. (D) Diaphoresis (sweating) occurs with hyperthyroidism, not hypothyroidism. (Test-taking hint: One way of determining the effectiveness of medication is to determine if the signs/symptoms of the disease are no longer noticeable.)
(16) The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? (A) Increase the regular insulin IV drip. (B) Check the client's urine for ketones. (C) Provide the client with a therapeutic diabetic meal. (D) Notify the HCP to obtain an order to decrease insulin.
(A) The regular intravenous insulin is continued because ketosis is not present, as with DKA. (B) The client diagnosed with type 2 diabetes does not excrete ketones in HHNS because there is enough insulin to prevent fat breakdown but not enough to lower blood glucose. (C) The client may or may not feel like eating, but it is not the appropriate intervention when the blood glucose level is reduced to 300 mg/dL. (D) WHEN THE GLUCOSE LEVEL IS DECREASED TO AROUND 300 MG/DL, THE REGULAR INSULIN INFUSION THERAPY IS DECREASED. SUBCUTANEOUS INSULIN WILL BE ADMINISTERED PER SLIDING SCALE. (Test-taking hint: When 2 options are the opposite of each other, they can either be eliminated or can help eliminate the other two options as incorrect answers. Options "2" and "3" do not have insulin in the answer; therefore, they should be eliminated as possible answers.)
(83) The nurse is preparing to administer the following medications. Which medication should the nurse question administering? (A) The thyroid hormone to the client who does not have a T3, T4 level. (B) The regular insulin to the client with a blood glucose level of 210 mg/dL. (C) The loop diuretic to the client with a potassium level of 3.3 mEq/L. (D) The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.
(A) The thyroid hormone must be administered daily, and thyroid levels are drawn every 6 months or so. (B) A blood glucose level of 210 mg/dL requires insulin administration; therefore, the nurse should not question administering this medication. (C) THIS POTASSIUM LEVEL IS BELOW NORMAL, WHICH IS 3.5-5.5 MEQ/L. THEREFORE, THE NURSE SHOULD QUESTION ADMINISTERING THIS MEDICATION BECAUSE LOOP DIURETICS CAUSE POTASSIUM LOSS IN THE URINE. (D) The digoxin level is within therapeutic range - 0.8 to 2.0 mg/dL; therefore, the nurse should administer this medication. (Test-taking hint: When administering medication, the nurse must know when to question the medication, how to know it is effective, and what must be taught to keep the client safe while taking the medication. The test taker may want to turn the question around and say, "I should give this medication."
(82) The nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, "Why don't the people in the United States get goiters as often?" Which statement by the nurse is the best response? (A) "It is because of the screening techniques used in the United States." (B) "It is a genetic predisposition rare in North Americans." (C) "The medications available in the United States decrease goiters." (D) "Iodized salt help prevent the development of goiters in the United States."
(A) There is no screening for thyroid disorders, just serum thyroid levels. (B) This is not a true statement. (C) Medications do not decrease the development of goiters. (D) ALMOST ALL OF THE IODINE ENTERING THE BODY IS RETAINED IN THE THYROID GLAND. A DEFICIENCY IN IODINE WILL CAUSE THE THYROID GLAND TO WORK HARD AND ENLARGE, WHICH IS CALLED A GOITER. GOITERS ARE COMMONLY SEEN IN GEOGRAPHICALLY REGIONS HAVING AN IODINE DEFICIENCY. MOST TABLE SALT IN THE UNITED STATES HAS IODINE ADDED. (Test-taking hint: The nurse must know about disease processes. There is no Test-Taking Hint to help with knowledge.)
(84) Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? (A) Obstipation and hypoactive bowel sounds. (B) Hyperpyrexia and extreme tachycardia. (C) Hypotension and bradycardia. (D) Decreased respirations and hypoxia.
(A) These are signs of myxedema (hypothyroidism) coma. Obstipation is extreme constipation. (B) HYPERPYREXIA (HIGH FEVER) AND HEART RATE ABOUT 130 BEATS PER MINUTE ARE SIGNS OF THYROID STORM, A SEVERELY EXAGGERATED HYPERTHYROIDISM. (C) Decreased blood pressure and slow heart rate are signs of myxedema coma. (D) These are signs/symptoms of myxedema coma. (Test-taking hint: If the test taker does not have the knowledge to answer the question, the test taker should look at the options closely. Options "1," "3," and "4" all have signs/symptoms of "decrease" - hypoactive, hypotension, and hypoxia. The test taker should selet the option which does not match.)
(22) The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? (A) The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. (B) The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. (C) The client with DKA who has multifocial premature ventricular contractions. (D) The client with HHNS who has a plasma osmolarity of 290 mOsm/L.
(A) This blood glucose level is elevated, but not life threatening, in the client diagnosed with type 2 diabetes. Therefore, a less experienced nurse could care for this client. (B) Hypoglycemia is an acute complication of type 1 diabetes, but it can be managed by frequent monitoring, so a less experienced nurse could care for this client. (C) MULTIFOCAL PVCS, WHICH ARE SECONDARY TO HYPOKALEMIA AND CAN OCCUR IN CLIENTS WITH DKA, ARE A POTENTIALLY LIFE-THREATENING EMERGENCY. THIS CLIENT NEEDS AN EXPERIENCED NURSE. (D) A plasma osmolarity of 280-300 mOsm/L is within normal limits; therefore, a less experienced nurse could care for this client. (Test-taking hint: The test taker must select the client with an abnormal, unexpected, or life-threatening sign/symptom for his or her disease process and assign this client to the most experienced nurse.)
(18) Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? (A) The client has tented skin turgor and dry mucous membranes. (B) The client is alert and oriented to date, time, and place. (C) The client's ABG results are pH 7.29, PaCO2 44, HCO3 15. (D) The client's serum potassium level is 3.3 mEq/L.
(A) This indicates the client is dehydrated, which does not indicate the client is getting better. (B) THE CLIENT'S LEVEL OF CONSCIOUSNESS CAN BE ALTERED BECAUSE OF DEHYDRATION AND ACIDOSIS. IF THE CLIENT'S SENSORIUM IS INTACT, THE CLIENT IS GETTING BETTER AND RESPONDING TO THE MEDICAL TREATMENT. (C) These ABGs indicate metabolic acidosis; therefore, the client is not responding to treatment. (D) This potassium level is low and indicates hypokalemia, which shows the client is not responding to medical treatment. (Test-taking hint: The phrase "responding to medical treatment" is asking the test taker to determine which data indicate the client is getting better. The correct answer will be normal data, and the other 3 options will be signs/symptoms of the disease process or condition.)
(11) The nurse at a freestanding health care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? (A) Ask the client if he has somewhere he can go and live. (B) Arrange for someone to give him insulin at a local homeless shelter. (C) Notify Adult Protective Services about the client's situation. (D) Ask the HCP to take the client off insulin because he is homeless.
(A) This is an example of interviewing the client; it is not an example of client advocacy. (B) CLIENT ADVOCACY FOCUSES SUPPORT ON THE CLIENT'S AUTONOMY. EVEN IF THE NURSE DISAGREES WITH HIS LIVING ON THE STREET, IT IS THE CLIENT'S RIGHT. ARRANGING FOR SOMEONE TO GIVE HIM HIS INSULIN PROVIDES FOR HIS NEEDS AND ALLOWS HIS CHOICES. (C) Adult Protective Services is an organization investigating any actual or potential abuse in adults. This client is not being abused by anyone. (D) The client needs the insulin to control the diabetes, and talking to the HCP about taking him off a needed medication is not an example of advocacy. (Test-taking hint: Remember, the test taker must understand what the question is asking and the definition of the terms.)
(78) Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? (A) Thyroid hormones. (B) Oxygen. (C) Sedatives. (D) Laxatives.
(A) Thyroid hormones are the treatment of choice for the client diagnosed with hypothyroidism; therefore, the nurse should not question this medication. (B) In untreated hypothyroidism, the medical management is aimed at supporting vital functions, so administering oxygen is an appropriate medication. (C) UNTREATED HYPOTHRYOIDISM IS CHARACTERIZED BY AN INCREASED SUSCEPTIBILITY TO THE EFFECTS OF MOST HYPNOTIC AND SEDATIVE AGENTS; THEREFORE, THE NURSE SHOULD QUESTION THIS MEDICATION. (D) Clients with hypothryoidism become constipated as a result of decreased metabolism, so laxatives should not be questioned by the nurse. (Test-taking hint: When a question asks which order the nurse should question, 3 of the options are medications the nurse expects to administer to the client. Sometimes saying, "The nurse administers this medication," may help the test taker select the correct answer.)
(1) An 18-year-old female client, 5'4'' tall, weighing 113 kg, comes to the clinic for a nonhealing would on her lower leg, which she has had for 2 weeks. Which disease process should the nurse suspect the client has developed? (A) Type 1 diabetes. (B) Type 2 diabetes. (C) Gestational diabetes. (D) Acanthosis nigricans.
(A) Type 1 diabetes usually occurs in young clients who are underweight. In this disease, there is no production of insulin from the beta cells in the pancreas. People with type 1 diabetes are insulin dependent with a rapid onset of symptoms, including polyuria, polydipsia, and polyphagia. (B) TYPE 2 DIABETES IS A DISORDER USUALLY OCCURRING AROUND THE AGE OF 40, BUT IT IS NOW BEING DETECTED IN CHILDREN AND YOUNG ADULTS AS A RESULT OF OBESITY AND SEDENTARY LIFESTYLES. NONHEALING WOUNDS ARE A HALLMARK SIGN OF TYPE 2 DIABETES. THIS CLIENT WEIGHS 248.6 LBS AND IS SHORT. (C) Gestational diabetes occurs during pregnancy. (D) Acanthosis nigricans (AN), dark pigmentation and skin creases in the neck, is a sign of hyperinsulinemia. The pancreas is secreting excess amounts of insulin as a result of excessive caloric intake. It is identified in young children and is a precursor to the development of type 2 diabetes. (Test-taking hint: The test taker must be aware of kilograms and pounds. The stem is asking about a disease process and acanthosis nigricans is a clinical manifestation of a disease, not a disease itself. Therefore, the test taker should not select this as a correct answer.)
(81) The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply. (A) Notify the HCP is a 3 lb weight loss occurs in 2 days. (B) Discuss ways to cope with the emotional lability. (C) Notify the HCP if taking over-the-counter medication. (D) Carry a medical identification card or bracelet. (E) Teach how to take thyroid medications correctly.
(A) WEIGHT LOSS INDICATES THE MEDICATION MAY NOT BE EFFECTIVE AND WILL PROBABLY NEED TO BE INCREASED. (B) THE CLIENT NEEDS TO KNOW EMOTIONAL HIGHS AND LOWS ARE SECONDARY TO HYPERTHYROIDISM. WITH TREATMENT, THE EMOTIONAL LABILITY WILL SUBSIDE. (C) ANY OVER-THE-COUNTER MEDICATIONS (FOR EXAMPLE, ALCOHOL-BASED MEDICATIONS) MAY NEGATIVELY AFFECT THE CLIENT'S HYPERTHYROIDISM OR MEDICATIONS BEING USED FOR TREATMENT. (D) THIS WILL HELP ANY HCP IMMEDIATELY KNOW OF THE CLIENT'S CONDITION, ESPECIALLY IF THE CLIENT IS UNABLE TO TELL THE HCP. (E) The client with hyperthyroidism will be on antithyroid medications, not thyroid medications. (Test-taking hint: This alternate-type question instructs the test taker to select all the interventions which apply. The test taker must read and evaluate each option as to whether it applies or not.)
(4) The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin by sliding scale. The order reads blood glucose level: <150, 0 units; 151-200, 3 units; 201-250, 6 units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?
3 UNITS -The client's result is 189, which is between 151 and 200, so the nurse should administer 3 units of Humalog insulin subcutaneously. (Test-taking hint: The test taker must be aware of the way the HCPs write medication orders. HCPs order insulin on a sliding scale according to a range of blood glucose levels.)
