Exam 3
With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? Select all that apply. A. Applying lotion during a back rub B. Brushing the client's teeth C. Emptying a Foley catheter reservoir D. Feeding the client E. Filing the client's fingernails F. Providing perineal care
B C F Not d- you do not come into contact with patients fluids
A client has a white blood cell change in which the number of suppressor T-cells is way below normal and asks the nurse which type of health problem(s) could be expected as a result of this deficiency. What is the nurse's best response? A. "You will need to receive booster vaccinations more often because your ability to make antibodies is reduced." B. "Try to avoid crowds and people who are ill because you are now more susceptible to bacterial and viral infections." C. "You will be more prone to allergic reactions when exposed to allergens or drugs." D. "Your risk for cancer development is increased."
C
The nurse is preparing to give medications to a group of clients. Which drug is not appropriate to treat the disease with which it is matched? A. Rheumatoid arthritis—leflunomide B. Osteoarthritis—acetaminophen C. Acute gout—allopurinol D. Systemic lupus erythematosus—prednisone
C
A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? A. The client can reduce the dosages of the prescribed drugs. B. The virus is resistant to the current combination of drugs. C. The client no longer has AIDS. D. The drug therapy is effective.
D
A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL (6.0 mmol/L), and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action will the nurse take next? a. Instruct the client to continue with the current diet and metformin use. b. Discuss the need to check blood glucose several times every day. c. Talk about the possibility of adding rapid-acting insulin to the regimen. d. Ask the client about current dietary intake and medication use.
D The nurse's next action would be to assess the client's adherence to the currently prescribed diet and medications. The nurse would also check for any stressors or undocumented illnesses. Glycosylated hemoglobin (HbA1C) levels >8% indicate poor diabetes control and need for adherence to regimen or changes in therapy.Instructing the client to continue with current diet and metformin use is inappropriate without further assessment. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data. The HbA1C indicates that the client's average glucose level is higher than the target range, but discussing the need to check blood glucose several times every day assumes that the client is not compliant with the therapy and glucose monitoring. The nurse would not assume that adding insulin, which must be prescribed by the primary health care provider, is the answer without assessing the underlying reason for the treatment failure.
1. Which assessment finding of a client 10 hours after a subtotal thyroidectomy indicates to the nurse possible airway obstruction? a. The client is drooling. b. The oxygen saturation is 97%. c. The dressing has a moderate amount of serosanguinous drainage. d. The client responds to questions correctly but does not open the eyes while talking.
Drooling may be a normal response for some patients while sleeping; however, it is also a major indication of swelling in the neck that could result in airway obstruction. More assessment is needed to determine whether the client is in danger of losing his or her airway. The oxygen saturation is within normal limits for a healthy adult. A moderate amount of drainage may be more than expected but is not an indication of obstruction. After general anesthesia, most clients are sleepy. Not opening his or her eyes during a response to a question is not an indication of airway obstruction.
An adolescent with IDDM is learning about a diabetic diet. He asks the nurse if he will ever be able to go out to eat with his friends again. What is the most appropriate answer for the nurse to give? 1. "You can go out with them, but you should take your own snack with you." 2. "Yes. You will learn what foods are allowed so you can eat with your friends." 3. "When you get food out in a restaurant, be sure to order diet soft drinks." 4. "Eating out will not be possible on a diabetic diet. Why don't you plan to invite your friends to your house?"
Eating out with friends is very important to an adolescent. Snacks will be allowed on his diet. He should be taught how to use the exchange lists in managing his diet.
A nurse cares for a client who has hypothyroidism as a result of Hashimoto's thyroiditis. The client asks, "How long will I need to take this thyroid medication?" How should the nurse respond? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid function, you can stop the medication."
NS: C Hashimoto's thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy. The client will not be able to stop taking the medication.
The nurse is teaching a client with newly diagnosed type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? a. "I will begin exercising for at least an hour a day." b. "I will monitor my diet and avoid empty calories." c. "If I lose weight, I may not need to use the insulin anymore." d. "Weight loss can be a sign of diabetic ketoacidosis."
a
Which is the best referral that the community health nurse can suggest to a client who has been newly diagnosed with diabetes? a. American Diabetes Association (ADA) b. Centers for Disease Control and Prevention c. Primary health care provider office d. Pharmaceutical representative
a
The nurse is providing discharge teaching to a client with type 2 diabetes and peripheral neuropathy. Which statement by the client indicates a need for further teaching about injury prevention? a. "I can break in my shoes by wearing them all day." b. "I need to monitor my feet daily for blisters or skin breaks." c. "I will never go barefoot." d. "I need to quit smoking."
a Further teaching about injury prevention is needed when the client with diabetic peripheral neuropathy says that "I can break in my shoes by wearing them all day." Shoes need to be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering.People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated because if the client has diabetic neuropathy, stepping on something sharp or harmful would not be felt. Tobacco use further decreases peripheral circulation increasing the risk for vascular complications.
The nurse caring for four clients with diabetes has these activities to perform. Which activity is appropriate to delegate to unlicensed assistive personnel (UAP)? a. Perform a blood glucose check on a client who requires insulin. b. Verify the infusion rate on a continuous infusion insulin pump. c. Assess a client who reports tremors and irritability. d. Monitor a client who is reporting palpitations and anxiety.
a Performing bedside glucose monitoring is a task that may be delegated to UAPs because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients.Intravenous therapy and medication administration are not within the scope of practice for UAPs. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for UAPs. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.
The nurse working on a medical surgical endocrine unit has just received change-of-shift report. Which client will the nurse see first? a. Client with type 1 diabetes whose insulin pump is beeping "occlusion" b. Newly diagnosed client with type 1 diabetes who is reporting thirst c. Client with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L) d. Client with type 2 diabetes with a blood pressure of 150/90 mm Hg
a The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis.Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.
A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action will the nurse take first? a. Check the blood glucose. b. Administer oxygen. c. Offer reassurance. d. Attach a cardiac monitor.
a The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis.Based on the oxygen saturation, oxygen administration is not indicated. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.
The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? a. Client taking repaglinide (Prandin) who has nausea and back pain b. Client taking glyburide (Diabeta) who is dizzy and sweaty c. Client taking metformin (Glucophage) who has abdominal cramps d. Client taking pioglitazone (Actos) who has bilateral ankle swelling
b The nurse needs to first assess the client taking glyburide (Diabeta) who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible.Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.
The clinic nurse is providing teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? a. "If I become hyperglycemic, it is a medical emergency." b. "If I become hypoglycemic, I could become unconscious." c. "Medical personnel may need confirmation of my insurance." d. "I may need to be admitted to the hospital suddenly."
b The statement by the client that indicates a correct understanding about the need to wear a MedicAlert bracelet is, "If I become hypoglycemic, I could become unconscious." Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care.Hyperglycemia does not pose the same type of acute medical emergency as hypoglycemia unless it is severe and acidosis develops. Insurance information does not appear on a MedicAlert bracelet. Information on the MedicAlert bracelet may be helpful if a sudden hospitalization occurs when the client cannot communicate. However, it is standard procedure to assess blood glucose in that instance.
The nurse in the endocrine clinic is providing education for a client who has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction to the client about the disease and its management? a. Current lifestyle b. Educational and literacy level c. Sexual orientation d. Current energy level
b The statement by the diabetic client that indicates that teaching was effective is, "I must inspect my shoes for foreign objects before putting them on." To avoid injury or trauma to the feet, shoes need to be checked for foreign objects before the feet are inserted in them.Clients with diabetes would not go barefoot because foot injuries can occur in those clients who lack sensation. To avoid injury or trauma, a callus needs to be removed by a podiatrist, not by the client. To prevent injury, the client with diabetes must wear protective shoes for support and not canvas shoes.
A client newly diagnosed with diabetes is not ready to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? Select all that apply. a. Pathophysiology of diabetes b. Causes and treatment of hypoglycemia c. Dietary control of blood glucose d. Insulin administration e. Physical activity and exercise
b,d The priority information the nurse needs to teach the client and family about diabetes are the causes and treatment of hypoglycemia and proper insulin administration. This information is essential for the client's survival and must be understood by both the client and family to ensure client safety.The pathophysiology of diabetes and hyperglycemia is a topic for secondary teaching and is not a survival need or the priority during hospitalization. Dietary control and exercise regimen are important, but are not the priority during the acute care stay. The priority information the nurse needs to teach the client and family about diabetes are the causes and treatment of hypoglycemia and proper insulin administration. This information is essential for the client's survival and must be understood by both the client and family to ensure client safety.The pathophysiology of diabetes and hyperglycemia is a topic for secondary teaching and is not a survival need or the priority during hospitalization. Dietary control and exercise regimen are important, but are not the priority during the acute care stay.
A client with typically well controlled diabetes has a glycosylated hemoglobin (HbA1C) level of 9.4%. Which response by the nurse is most appropriate? a. "Keep up the good work." b. "This is not good at all." c. "Have you been doing something differently? d. "You need an increase in your insulin dose."
c A cold, mottled right great toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization. This must be reported to the primary health care provider to avoid potential gangrene and amputation.Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted.
Which of these clients with diabetes will the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? a. A client with sensory neuropathy who needs teaching about foot care b. A client with diabetic ketoacidosis who has an IV running at 250 mL/hr c. A client who needs blood glucose monitoring and insulin before each meal d. A client who was admitted with fatigue and shortness of breath
c A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit.The clients with sensory neuropathy, diabetic ketoacidosis, and the client with fatigue and shortness of breath all have specific teaching or assessment needs that are better handled by nurses more familiar with caring for adults with diabetes-related complications.
An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. When the cardiac monitor shows ventricular ectopy, which assessment will the nurse make? a. Urine output b. 12-lead electrocardiogram (ECG) c. Potassium level d. Rate of IV fluids
c After DKA therapy starts, serum potassium levels drop quickly. An ECG shows conduction changes and ectopy related to alterations in potassium. Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the ectopy is essential.Ectopy is not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause, which is most likely hypokalemia. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.
A client with type 2 diabetes controlled with Metformin is recovering from surgery. The primary health care provider has placed the client on insulin in addition to the metformin. What is the nurse's best response about why the client needs to take insulin? a. "Your diabetes is getting worse, so you will need to take insulin." b. "You can't take your metformin while in the hospital." c. Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." d. "You must take insulin from now on because the surgery will affect your diabetes."
c Stress, such as surgery, increases blood glucose levels. You'll need insulin to control your blood glucose temporarily." The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.
A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African-American c. A 44-year-old Asian d. A 48-year-old American Indian
d
The intensive care nurse is caring for a client admitted in a hyperglycemic-hyperosmolar state. Which of these prescriptions made by the primary health care provider will the nurse question? a. Add 20 mEq of KCl to each liter of IV fluid b. IV regular insulin at 2 units/hr c. IV normal saline at 100 mL/hr d. 1 ampule Sodium Bicarbonate IV now
d Sodium Bicarbonate is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state that presents with hyperglycemia and absence of ketosis/acidosis.Insulin puts potassium into the cell. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from osmotic diuresis and electrolyte shifts. IV regular insulin at 2 units/hr will help correct hyperglycemia. IV normal saline at 100 mL/hr will help correct dehydration.
A client recently admitted with new-onset type 2 diabetes will be discharged with a meter for self-monitoring of blood glucose (SMBG) levels. When is the best time for the nurse to explain to the client the proper use of the glucose monitor? a. Day of discharge b. On admission c. When the client states readiness d. While performing the test in the hospital
d Teaching the client about the operation of the machine while performing the test in the hospital is the best time for the nurse to introduce the client to SMBG. The teaching can be reinforced each time testing is performed on the client and again before discharge.Instructing the client on the day of admission or the day of discharge would not allow time for redemonstration and correction of the skill if needed. Other time-consuming activities are done on those days and could distract the client and make the client feel overwhelmed. Also, waiting for the client to state readiness may postpone the instructions too long.
The nurse in the endocrine clinic is reviewing type 1 and type 2 diabetes with a group of nursing students. Which explanation by the students indicates their understanding of the types of diabetes? a. Most clients with type 1 diabetes are born with it. b. People with type 1 diabetes are often obese. c. Those with type 2 diabetes make insulin, but in inadequate amounts. d. People with type 2 diabetes do not develop typical diabetic complications.
d The explanation by the students that indicate understanding of the type of diabetes is "Those with type 2 diabetes make insulin, but in inadequate amounts." People with type 2 diabetes may also have resistance to existing insulin.Most clients with type 1 diabetes are not born with it. Although type 1 diabetes may occur early in life, it is considered an autoimmune disorder in which beta cells are destroyed in a genetically susceptible person. Risk for type 1 DM is determined by inheritance of genes coding for the HLA-DR and HLA-DQA and DQB tissue types (McCance et al., 2014). However, inheritance of these genes only increases the risk, and most people with these genes do not develop type 1 DM. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for typical diabetic complications, especially cardiovascular diseases.
The nurse is performing an admission assessment on a 52-year-old client admitted with type 2 diabetes.Physical Assessment Diagnostic Findings Provider Prescriptions Lungs clear Glucose 179 mg/dL (9.9 mmol/L)Regular insulin 8 units if blood glucose 250 to 275 mg/dL (13.9 to 15.3 mmol/L)Right great toe mottled and cold to touch Hemoglobin A1c 6.9% Regular insulin 10 units if glucose 275 to 300 mg/dL (15.3 to 16.7 mmol/L)Client states wears eyeglasses to read After completing the above assessment, which complication of diabetes does the nurse report to the primary health care provider? a. Poor glucose control b. Visual changes c. Respiratory distress d. Decreased peripheral perfusion
d The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes.Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.
Which nursing action will the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? a. Assist the client's spouse in choosing appropriate dietary items. b. Evaluate the client's use of a home blood glucose monitor. c. Inspect the extremities for evidence of poor circulation. d. Assist the client with washing the feet and applying moisturizing lotion.
d The nursing action that the home health nurse can delegate to a home health aide who is making daily visits to a newly diagnosed type 2 diabetic client is assisting with personal hygiene. This action is included in the role of home health aides.Assisting with appropriate dietary selections, evaluating the effectiveness of teaching, and performing assessments are complex actions that would be performed by licensed nurses.
A 33-year-old woman has just returned from a 5-year mission trip to a less affluent country and is having a complete check-up. She is 25 lbs (11.3 kg) overweight and had an 11 lbs (5 kg) baby 2 years ago while on the mission trip. Her fasting blood glucose level is 119 mg/dL (6.5 mmol/L) and her A1C is 5.8. She reports that her mother, sister, and maternal grandmother all have type 2 DM. She asks what she can do about this possible health problem. 1. Does she have diabetes? Provide a rationale for your response. 2. What risk factors does she have for type 2 DM? 3. What additional assessment information should you obtain? 4. In addition to yourself and the health care provider, what other interprofessional health team members would be appropriate to consult at this time? 5. What life-style recommendations are appropriate for this patient? 6. Can this DM be prevented?
1. Does she have diabetes? Provide a rationale for your response. ANS: At this time she does not meet the criteria for actual DM but does have prediabetes because both her FBS and A1C are higher than completely normal. 2. What risk factors does she have for type 2 DM? ANS: Positive family history for the disorder, which is a genetic risk factor. She had a large infant, which is a strong predictor for development of DM type 2, and she is overweight. Being overweight is a huge risk factor for DM development. 3. What additional assessment information should you obtain? ANS: Blood pressure; examine lipid panel, ask whether she has had other children and what their birth weights were, ask about whether any testing was done during her pregnancy. 4. In addition to yourself and the health care provider, what other interprofessional health team members would be appropriate to consult at this time? ANS: She should be counseled by a registered dietitian for weight control. A diabetes educator at this time can really help her to understand her risks for the disease, as well as the possible complications and their consequences. Because she may have had prediabetes for some time, she should see an ophthalmologist for baseline studies of her retina and for measurement of both intraocular pressure and field testing. 5. What life-style recommendations are appropriate for this patient? ANS: Dietary changes for weight loss along with regular exercise could very well change her designation from prediabetes to healthy. However, because she is currently in the state of prediabetes, this condition would return if she should become less physically active or more overweight. It is very important for her to ensure good blood pressure management at this time (if she is found to be at all hypertensive now). If she has any degree of hypertension, weight control and exercise can help reduce it and its associated health risks. If diet and exercise alone do not keep her blood pressure within her target range, antihypertensives may be needed.
An elderly woman has been recently diagnosed as having Type 2 diabetes. Which of the following complaints that she has is most likely to be related to the diagnosis of diabetes mellitus? 1. Pruritus vulvae 2. Cough 3. Eructation 4. Singultus
1. Pruritus vulvae (itching of the vulva) frequently accompanies diabetes. Monilial infections are common due to the change in pH. Eructation is belching or burping, and singultus is hiccups. Neither of these is particularly related to diabetes.
A client who has just had a thyroidectomy returns to the unit in stable condition. What equipment is it essential for the nurse to have readily available? 1. Tracheostomy set 2. Thoracotomy tray 3. Dressing set 4. Ice collar
1. Swelling in the operative site could cause airway obstruction. The nurse should have a tracheostomy set and oxygen readily available for 48 hours after thyroidectomy. A thoracotomy tray is not indicated. This client is not likely to need intervention in the thoracic cavity. A dressing set is unlikely to be needed in the immediate postoperative period. An ice collar might be indicated but is not critical to have at the bedside.
At 10 A.M., a client with Type 1 diabetes becomes very irritable and starts to yell at the nurse. Which initial nursing assessment should take priority? 1. Blood pressure and pulse 2. Color and temperature of skin 3. Reflexes and muscle tone 4. Serum electrolytes and glucose
2- INITIAL NURSING ASSESSMENT!
Which finding would be the greatest cause for concern to the nurse during the early postoperative period following a thyroidectomy? 1. Temperature of 100°F 2. A sore throat 3. Carpal spasm when the blood pressure is taken 4. Complaints of pain in the area of the surgical incision
3. Carpal spasm is a sign of tetany and is known as Chvostek's sign. Tetany may occur if the parathyroid have been inadvertently removed or damaged. The parathyroid regulates calcium phosphorus balance. Hypocalcemia causes tetany. Most clients who have been intubated during surgery have a sore throat. Pain in the incision area is normal in the immediate postoperative period.
An elderly client with Type 2 diabetes mellitus develops an ingrown toenail. What is the best action for the nurse to take? 1. Put cotton under the nail and clip the nail straight across 2. Elevate the foot immediately 3. Apply warm, moist soaks 4. Notify the physician
4
Which problem is most likely to develop if hyperthyroidism remains untreated? 1. Pulmonary embolism 2. Respiratory acidosis 3. Cerebral vascular accident 4. Heart failure
4. Hyperthyroidism causes tachycardia, which can be severe enough to cause heart failure. Pulse rates can be 100 to 150 per minute.
Which treatment is used to manage hyperthyroidism? Select all that apply. A. Irradiation of the thyroid. B. Administration of oral thyroid hormones. C. Thyroidectomy. D. Nephrectomy.
A & C. Irradiation destroys the thyroid gland while a thyroidectomy involves completely removing the gland. Oral thyroid hormones treat hypothyroidism. A nephrectomy involves removal of the kidney.
A client had a left anterior total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? Select all that apply. A. "Avoid extending your left hip behind you when you sit." B. "Do not flex your hips more than 90 degrees when toileting." C. "You may cross your legs to be more comfortable in a chair." D. "Avoid twisting your body when moving or performing ADLs." E. "Stand on your right leg and pivot into the chair when getting out of bed."
A, D, E
Which health teaching by the nurse is important for clients diagnosed with systemic lupus erythematosus? Select all that apply. A. "Take frequent rest periods to prevent fatigue." B. "Avoid green leafy vegetables to prevent bleeding." C. "Avoid sun exposure to prevent disease flare-ups." D. "Report fever to your health care provider immediately" E. "Use a mild soap for bathing to prevent skin irritation."
A,C,D,E Systemic lupus erythematosus is a systemic autoimmune disease that causes fatigue, organ failure, and skin lesions and rashes that are worsened by ultraviolet light such as sunlight.
Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? Select all that apply. A. Bony nodes in finger joints B. Subcutaneous nodules C. Severe weight loss D. Joint deformity E. Thrombocytosis
ALL OF THEM
15. A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How should the nurse respond? a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." b. "Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light." c. "Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes." d. "No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container."
ANS: A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.
A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How should the nurse respond? a. "Your risk of diabetes is higher than the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes mellitus." c. "The risk for becoming a diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes mellitus, but male children will."
ANS: A Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.
A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.
ANS: A The client's blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client's blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the client's blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.
1. Which physiologic actions result from normal insulin secretion? (Select all that apply.) a. Increased liver storage of glucose of glycogen b. Increased gluconeogenesis c. Increased cellular uptake of blood glucose d. Increased breakdown of lipids (fats) for fuel e. Increased production and release of epinephrine f. Decreased storage of free fatty acids in fat cells g. Decreased blood glucose levels h. Decreased blood cholesterol levels
ANS: A, C, G, H The main metabolic effects of insulin are to stimulate glucose uptake in skeletal muscle and heart muscle and to suppress liver production of glucose and very-low-density lipoprotein (VLDL). In the liver, insulin promotes the production and storage of glycogen (glycogenesis) at the same time that it inhibits glycogen breakdown into glucose (glycogenolysis). It increases protein and lipid (fat) synthesis and inhibits ketogenesis (conversion of fats to acids) and gluconeogenesis (conversion of proteins to glucose). In muscle, insulin promotes protein and glycogen synthesis. In fat cells, it promotes triglyceride storage. Overall, insulin keeps blood glucose levels from becoming too high and helps keep blood lipid levels in the normal range.
Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? a. 75-year-old client whose blood glucose levels show little variation b. 55-year-old client who has hypoglycemic unawareness c. 80-year-old client with type 2 diabetes mellitus d. 45-year-old client with type 1 diabetes mellitus
ANS: B Comparison studies have shown wide variation between fingertip and alternate sites, and variation is most evident during times when blood glucose levels are rapidly changing. Teach patients that there is a lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Because of this lag time, clients who have hypoglycemic unawareness should never use alternate sites for SMBG.
1. Which statement by a client undergoing radioactive iodine (RAI) therapy demonstrates to the nurse that the client has correct understanding of post-procedure precautions? a. "I will wear a wig until my hair grows back in." b. "I will be sure to use only one toilet and not let others use it for 2 weeks." c. "I will avoid crowds and people who are ill to reduce the risk for an infection." d. "I will avoid having a manicure or pedicure during the first month after treatment"
ANS: B The client's urine will contain small amounts of radioactive iodine that can pose a hazard to others, particularly if it is absorbed through mucous membranes. Until the client has completely cleared this material, he or she should use a separate toilet. Radioactive iodine therapy does not result in significant hair loss, nor does it reduce immunity. There is no risk for exposure of the radioactive material during either a pedicure or a manicure.
A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How should the nurse respond? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."
ANS: B Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the client's risk of insulin shock.
A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this client's plan of care? a. Ask the client to ambulate in the hallway twice a day. b. Use a lift sheet to assist the client with position changes. c. Provide the client with a soft-bristled toothbrush for oral care. d. Instruct the unlicensed assistive personnel to strain the client's urine for stones.
ANS: B Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for this client.
A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the client's liver function study results. c. Instruct the client to increase water intake.d. Test a sample of urine for occult blood.
ANS: B Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client's most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake.
1. Which symptoms are most often seen in hypothyroidism? (Select all that apply.) a. Increased appetite b. Cold intolerance c. Constipation d. Hypotension e. Exophthalmia f. Palpitations g. Tremors h. Weight gain
ANS: B, C, D, H Hypothyroidism slows metabolism way below normal. Appetite is decreased, not increased. The client may not generate sufficient heat to maintain core body temperature. The GI system is slowed, resulting in constipation. Cardiac output decreases leading to hypotension. Exophthalmia is a complication of the Grave's form of hyperthyroidism. Palpitations and tremors occur when the central nervous system and the cardiovascular system are overstimulated by hypermetabolism. They are not associated with hypometabolism. Because metabolism is slowed, caloric use for energy decreases and weight is gained even when intake is not excessive
A nurse working in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Perform a physical assessment. B. Determine when current symptoms began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.
ANS: B, C, F Standard Precautions for preventing the spread of any type of infection including HIV requires wearing gloves when coming into contact with moist mucous membranes, including oral and perineal membranes. Although saliva has a low concentration of HIV unless blood is present, oral mucous membranes harbor many types of infectious organisms. Standard precautions also require that gloves be worn when contact with urine is possible, including during such tasks as emptying a Foley catheter reservoir. Perspiration is not considered a body fluid with risk for transmission and neither is in contact with the client's intact skin. Feeding the client should not result in direct contact with transmissible fluids and neither should clipping finger nails.
Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes? a. "Avoid drinking ice-cold beverages." b. "Be sure to check your blood pressure twice daily." c. "Change positions slowly when moving from sitting to standing." d. "Check your hands and feet weekly for areas of numbness or sensation change."
ANS: C Cardiovascular autonomic neuropathy (CAN) affects sympathetic and parasympathetic nerves of the heart and blood vessels. This problem contributes to left ventricular dysfunction, painless myocardial infarction, and exercise intolerance. Most often, CAN leads to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing). These problems are from failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. As a result, blood flow to the brain is interrupted briefly. Orthostatic hypotension and syncope increase the risk for falls, especially among older adults. Although checking blood pressure twice daily is helpful, it does not prevent orthostatic hypotension, nor is there any guarantee that such hypotension will occur during blood pressure measurement. Sensation changes are associated with peripheral neuropathy, not cardiovascular autonomic neuropathy. Avoiding cold beverages is no longer a recommended action.
1. A 45-year-old client is receiving subcutaneous injections of a biologic therapy for plaque psoriasis. Which condition will the nurse immediately report to the health care provider? a. Missed injection b. Increased pruritus c. Cough with fever d. New plaques on leg
ANS: C Cough with fever are indications of an active infection requiring immediate discontinuation of the biologic, and notification of the health care provider. The nurse can educate the client about how to proceed after a missed injection. New plaques on the leg and increased pruritus are not as concerning as an active infection.
A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client? a. Heat intolerance b. Body image problems. c. Depression and withdrawal d. Obesity and water retention
ANS: C. Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The client's family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the client's environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.
1. A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? a. The client can reduce the dosages of the prescribed drugs. b. The virus is resistant to the current combination of drugs. c. The client no longer has AIDS. d. The drug therapy is effective.
ANS: D A client diagnosed with AIDS meets the criteria for Stage 3 category of HIV infection. Even when this client's CD4+ T-cell count increases as a result of therapy, the diagnosis of AIDS remains. The fact that the T-cell count has risen indicates that the combination of drugs used for therapy is effective; however, the dosages are not decreased.
The nurse reviewing the laboratory work of a client with hypoparathyroidism finds all the following blood values. For which value does the nurse immediately assess the client's reflexes? a. Sodium 131 mEq/L (mmol/L~) b. Potassium 5.1 mEq/L (mmol/L~) c. Calcium 7.8 mg/dL (1.76 mmol/L~) d. pH 7.33
ANS: D All of the laboratory values are somewhat out of the normal range but do not reach critical values. Sodium is slightly decreased, potassium is slightly elevated, and pH is a little low. Even though severe hyponatremia can result in seizures, it must be much lower for this complication to occur. Only the serum calcium level is low enough to indicate severe problems and a greatly increased risk for seizure activity. Assessing the client's reflexes can provide a reasonable determination of risk severity.
The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 82 mg/dL (mmol/L) and a hemoglobin A1c (A1C) of 5.9%. What is the nurse's interpretation of these findings? a. The client's glucose control for the past 24 hours has been good but the overall control is poor. b. The client's glucose control for the past 24 hours has been poor but the overall control is good. c. The values indicate that the client has poorly managed his or her disease. d. The values indicate that the client has managed his or her disease well.
ANS: D Fasting blood glucose levels provide an indication of the client's adherence to drug and nutrition therapy for DM has been for the previous 24 hours. This client's FBG is well within the normal range. A1C provides an indication of general blood glucose control for the past several months because when glucose attaches to hemoglobin, the attachment is permanent for as long as those hemoglobin molecules are present within red blood cells. Normal red blood cell life span is about 120 days. This client's A1C level is within the desirable range, indicating good long-term glucose control as well as short-term control.
After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor when I have a vision problem and yearly after age 40." c. "My vision will change quickly. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."
ANS: D Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.
17. After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise."
ANS: D Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.
A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? a. Serum potassium: 2.9 mEq/L b. Serum magnesium: 1.7 mEq/L c. Serum sodium: 122 mEq/L d. Serum calcium: 6.9 mg/dL
ANS: D Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions (Trousseau's sign) that occur during blood pressure measurement are indicative of hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyponatremia, and hypomagnesemia.
A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective? a. Thirst is recognized and fluid intake is appropriate. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3. d. Heart rate is 70 beats/min and regular.
ANS: D Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a client's heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic response to this medication.
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
ANS: D. Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open.
