exam 2 complex care practice questions
Which statement by a client who had a transient ischemic attack (TIA) and is at risk for stroke indicates a need for further health teaching by the nurse? A. "I'm glad I can keep eating protein like red meat." B. "I'll try to walk at least 20-30 minutes each day." C. "I'm going to talk to my doctor about a weight loss plan." D. "I plan to include more fruits and vegetables in my diet."
A Rationales: The client who has had a TIA needs to modify his or her lifestyle to promote health and prevent a stroke. Choices B, C, and D all indicate that the client realizes the need to exercise more, lose weight, and eat a healthy diet. Choice A shows that the client believes that red meat is also healthy but it contains high levels of saturated fat which can clog arteries and decrease Perfusion.
A client experiences a seizure that is observed by the nurse. What will the nurse document in the client's medical record? SATA A. Time that the seizure began and ended B. Whether the seizure was preceded by an aura C. What the client does after the seizure D. How long it takes for the client to return to pre-seizures status E. The drugs that are administered during the seizure
A, B, C, D Rationales: All of the choices are correct except for E because drugs are not given during a single seizure.
1. The nurse reassesses a client who was admitted 8 hours after stroke symptoms began and documents the following findings. Which assessment findings would the nurse report immediately to the primary health care provider? Select all that apply. A. Blood pressure increase to 196/100 B. Heart rate of 88 beats per minute C. Respiratory rate of 22 breaths per minute D. New onset headache reported as 8/10 pain intensity E. Increased drowsiness and dozing frequently F. Urine output of 360 mL since admission
A, D, E Rationale: The client's increase in blood pressure, intense headache, and decreasing level of consciousness implies that the client is most likely experiencing either an increase in intracranial pressure or is presenting with stroke symptoms. In either case, the nurse would report these new findings (Choices A, D, E) to the primary health care provider or Rapid Response Team. The client's heart and respiratory rate are within normal limits (Choices B and C), and the client is producing an adequate amount of urine given the minimum output should be at least 30 mL/hour.
Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply. A. Gluconeogenesis B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lypogenesis F. Lypolysis
A,C Rationale: Gluconeogenesis is the conversion of protein into glucose. This process increases blood glucose levels and prevents hypoglycemia during fasting. Glycogenolysis is the breakdown of stored glycogen in the liver and skeletal muscle and conversion to glucose. It is the main process that prevents hypoglycemia during fasting. Glycogenesis is the conversion by the liver of excess circulating glucose into glycogen. This process reduces blood glucose levels and does not directly prevent hypoglycemia. Ketogenesis is the breakdown of fats (lipids) into ketone bodies that can be used for fuel by some cells. It does not raise blood glucose levels and does not directly prevent hypoglycemia. Lypogenesis is the conversion of glucose (and other substances) into body fats, usually as free fatty acids. This process does not prevent hypoglycemia during fasting. Lypolysis is the breakdown of fatty acids but does not convert them to glucose and does not directly prevent hypoglycemia during fasting.
Which precaution is a priority for the nurse to teach a client prescribed semaglutide to prevent harm? A. Only take this drug once weekly. B. Report any vision changes immediately. C. Do not mix in the same syringe with insulin. D. This drug can only be given by a health care professional.
A. Rationale: Semaglutide is a long-acting GLP-1 agonist given only once weekly and comes only as a self-injection pen. It does not have to be administered by a health care professional. It is not associated with any vision changes.
How will the nurse modify insulin injection technique for a client who is 5 feet 10 inches tall and weighs 106 lb (48.1 kg) A. Use a 6 mm needle and inject at a 90-degree angle. B. Use a 6 mm needle and inject at a 45-degree angle. C. Use a 12 mm needle and inject at a 90-degree angle. D. Use a 12 mm needle and inject at a 45-degree angle.
Answer: B Rationale: The client is very thin. Using either a longer needle or injecting the insulin at a 90-degree angle increases the likelihood of performing an intramuscular injection instead of a subcutaneous one, which would affect insulin absorption. Selecting a shorter needle and injecting at a 45-degree angle prevents an intramuscular injection into this client.
While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, slightly confused, and can still swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT does of glucagon B. Immediately give the client 30 grams of glucose orally C. Start an IV and administer 50 mL of a 50% dextrose solution D. Recheck the blood glucose level and call the rapid response team
B Rationale: The client's blood glucose level is seriously low and will get even lower quickly. Because the client can still swallow, giving 30 grams of glucose (following the 15-15 rule) is the best course of action. Obtaining a dose of glucagon from the pharmacy or starting an IV are too slow to prevent severe hypoglycemia. Just rechecking the blood glucose level without giving glucose is very dangerous when the client already has symptoms of hypoglycemia.
The nurse is caring for a client treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse to report to the primary health care provider? A. Client has a mild headache. B. Client's blood pressure is 194/120. C. Client has left hemiparesis. D. Client continues to be drowsy.
B Rationales: The assessment findings in Choices C and D are not new and are likely related to the client's stroke. Having a mild headache is not unusual for clients who have a stroke but a severe headache during or after fibrinolytic therapy would be a major concern. During or after alteplase administration, the expected outcome for the client's blood pressure is to keep it below 185/110. The blood pressure in Choice B is very high and needs to be immediately reported to the primary health care provider who will likely prescribe a rapid-acting anti-hypertensive drug.
A client with diabetes who now has chronic albuminuria asks the nurse how this change will affect his health. How will the nurse answer this question? A. "You will need to limit your intake of dietary albumin and other proteins to reduce the albuminuria." B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage." C. "Your risk for developing urinary tract infections is greatly increased, requiring the need to take daily antibiotics for prevention." D. "From now on you will need to keep your fluid intake to just 1 L daily and completely avoid caffeine to protect your kidneys."
B Rationale: The microvascular complications of diabetes reduce kidney perfusion and damage the glomeruli, leading to chronic kidney disease. The first indication of this problem is chronic albuminuria from increased filtration of proteins through damage glomeruli. Although this problem cannot be reversed, the rate of progression can be slowed with tight glycemic control. With albuminuria, proteins are lost from the body and do need to be replaced, not restricted, at this stage. The risk for urinary tract infections is increased with glucose in the urine, not albumin or other protein. Reducing fluid intake has the potential to damage the kidneys further and is not helpful
Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing "flip-flops" when you are at home."
B, C Rationale: Regardless of whether diabetes is type 1 or type 2, the long-term complications are the same as are most prevention activities. The microvascular complications of diabetes increase the risk for eye and vision problems for all who have the disorder. Annual examinations by an ophthalmologist are critical to preventing or delaying reduced vision. Hypercholesterolemia is common in diabetes and contributes to hypertension, as well as microvascular and macrovascular complications, especially cardiovascular
Which hormones help prevent hypoglycemia? Select all that apply. A. Aldosterone B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon F. Insulin G. Norepinephrine H. Proinsulin
B, C, D, E, G Rationale: Cortisol decreases glucose uptake by cells and increases liver production and release of glucose. Epinephrine and norepinephrine rapidly increase liver glycogen breakdown and release of glucose into circulation. Growth hormone also rapidly increases liver glycogen breakdown and increases release of glucose into circulation. Glucagon is the major hormone preventing hypoglycemia. It is produced and secreted by alpha cells of the pancreatic islets as soon as blood glucose levels begin to drop below normal. Aldosterone is an adrenal hormone that affects water and mineral metabolism, not glucose metabolism. Insulin decreases blood glucose levels and can cause hypoglycemia. Proinsulin is an inactive compound that does not directly affect blood glucose levels until it is metabolized into insulin.
The nurse is caring for an older client with receptive (sensory) aphasia. Which nursing action is most appropriate for communicating with the client? A. Refer the client to the speech-language pathologist (SLP). B. Speak loudly to help the client interpret what is being said. C. Provide pictures to help the client understand. D. Ask the client to read messages on a white board.
C Rationales: The client who has receptive (sensory) aphasia cannot understand either verbal or written words. Therefore, Choice D is an incorrect response. Speaking loudly does not help the client better understand what is being said, so Choice B is also an incorrect response. While it is feasible to refer the client to the SLP, that action will not help now with communication (Choice A). Choice C is the most appropriate action to help the client understand what is being communicated.
When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature. B. Return the vial to the pharmacy and open a fresh vial of NPH insulin. C. Roll the vial between the hands until the insulin is clear. D. Check the expiration date and draw up the insulin dose.
D Rationale: The character of NPH insulin is uniformly cloudy. If the expiration date has not passed it can be safely used. Insulin should never be warmed by placing the vial in water.
The nurse reviewing the preadmission testing laboratory values for a 62-year-old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding? A. The client's A1C is completely normal B. The client has type 1 diabetes mellitus C. The client has type 2 diabetes mellitus D. The client has prediabetes mellitus
D Rationale: The normal range for A1C (glycosylated hemoglobin A1c) is between 4% and 6%, with diabetes defined as a consistent level above 6.5%. However, clients whose AIC range between 5.7% and 6.4% are considered to have prediabetes with a greatly increased risk for development of actual diabetes mellitus within the next 5 years. Thus this value is not completely normal and is of concern. A1C levels do not distinguish between type 1 and type 2 diabetes.
1. A client is admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia which resulted from a traumatic brain injury. Which of the following interventions is a priority for the client at this time? A. Contact the physical therapist (PT) to plan care to increase the client's mobility. B. Contact the occupational therapist (OT) to assess the client's ADL ability. C. Contact the unit social worker (SW) to talk with the family about his discharge. D. Contact the speech/language pathologist (SLP) to schedule a swallowing study.
D Rationale: The nurse will likely need to collaborate with all of these interprofessional health care team members. However, the priority at this time is to ensure that the client remains NPO until a bedside swallowing study can be conducted to prevent possible aspiration when the client eats food or drinks liquids. If there is a swallowing problem, the SLP makes recommendations for special swallowing precautions and communicates those interventions to the members of the health care team.
