Endocrine
A nurse teaches a patient who is prescribed an unsealed radioactive isotope. Which statements will the nurse include in this patient's education? (Select all that apply.) a. "Do not share utensils, plates, and cups with anyone else." b. "Wash your clothing separate from others in the household." c. "Take a laxative 2 days after therapy to excrete the radiation." d. "You can play with your grandchildren for 1 hour each day."
A. "Do not share utensils, plates, and cups with anyone else." B. "Wash your clothing separate from others in the household." C. "Take a laxative 2 days after therapy to excrete the radiation."
A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism? a. "I am always tired, even with 12 hours of sleep." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "My sister has thyroid problems."
A. "I am always tired, even with 12 hours of sleep."
A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does the nurse respond? a. "You'll need thyroid pills for life because your thyroid won't start working again." b. "You will need to take the thyroid medication until the goiter is completely gone." c. "When blood tests indicate normal thyroid function, you can stop the medication." d. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication."
A. "You'll need thyroid pills for life because your thyroid won't start working again."
A nurse evaluates the following laboratory results for a patient who has hypoparathyroidism: Calcium 7.2 mg/dL (1.8 mmol/L)Sodium 144 mEq/L (144 mmol/L)Magnesium 1.2 mEq/L (0.6 mmol/L)Potassium 5.7 mEq/L (5.7 mmol/L)Based on these results, which medications does the nurse anticipate administering? (Select all that apply.) a. 50% magnesium sulfate b. Oral potassium chloride c. Oral calcitriol (Rocaltrol) d. Intravenous calcium chloride e. 3% normal saline IV solution
A. 50% magnesium sulfate D. Intravenous calcium chloride
A nurse teaches a patient with hyperthyroidism. Which dietary modifications should the nurse include in this patient's teaching? (Select all that apply.) a. Increased calorie intake b. Increased carbohydrates c. Decreased fats d. Increased proteins
A. Increased calorie intake B. Increased carbohydrates D. Increased proteins
A nurse cares for a patient who is recovering from a pituitary gland resection (hypophysectomy). What action would the nurse take first? a. Report clear or light yellow drainage from the nose. b. Instruct the patient to cough, turn, and deep breathe. c. Apply petroleum jelly to lips to avoid dryness d. Keep the head of the bed flat and the patient supine.
A. Report clear or light yellow drainage from the nose
A nurse cares for a patient who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.) a. Urine output is decreased. b. Urine osmolality is decreased. c. Specific gravity is increased. d. Urine osmolality is increased. e. Specific gravity is decreased. f. Urine output is increased.
A. Urine output is decreased C. Specific gravity is increased D. Urine osmolality is increased.
A nurse is caring for a patient who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The patient's symptoms have now resolved and the patient asks, "When can I stop taking these medications?" How would the nurse respond? a. "The drug suppresses your immune system, which must be built back up." b. "Once you start corticosteroids, you have to be weaned off them." c. "It is possible for the inflammation to recur if you stop the medication." d. "You must decrease the dose slowly so your hormones will work again."
B. "Once you start corticosteroids, you have to be weaned off them."
At 4:45 PM, a nurse assesses a patient with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the patient is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) Dietary Intake At 06:30—95At 11:30—70At 16:30—47 Breakfast: 10% eaten—patient states that she is not hungry Lunch: 5% eaten—patient is nauseous; vomits once After reviewing the patient's assessment data, which action is appropriate at this time? a. Assess the patient's oxygen saturation level and administer oxygen. b. Administer dextrose 50% intravenously and reassess the patient. c. Provide a glass of orange juice and encourage the patient to eat dinner. d. Reorient the patient and apply a cool washcloth to the patient's forehead.
B. Administer dextrose 50% intravenously
A nurse cares for a patient who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? a. Atropine sulfate b. Levothyroxine sodium (Synthroid) c. Propranolol (Inderal) d. Epinephrine (Adrenalin)
B. Levothyroxine sodium (Synthroid)
A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level is 114 mEq/L (114 mmol/L). What action would the nurse take first? a. Consult with the dietitian about increased dietary sodium b. Restrict the patient's fluid intake to 600 mL/day. c. Handle the patient gently by using turn sheets for repositioning. d. Instruct unlicensed assistive personnel to measure intake and output.
B. Restrict the patient's fluid intake to 600 mL/day
While assessing a patient with Graves' disease, the nurse notes that the patient's temperature has risen 1° F (1° C). What does the nurse do first? a. Calculate the patient's apical-radial pulse deficit. b. Turn the lights down and shut the patient's door. c. Call for an immediate electrocardiogram (ECG). d. Administer a dose of acetaminophen (Tylenol).
B. Turn the lights down and shut the patient's door
A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has capillary blood glucose of 33 mg/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first? a. Encourage the patient to drink orange juice. b. Administer 25 mL dextrose 50% (D50) IV push. c. Administer 1 mg of intramuscular glucagon. d. Insert a new intravenous access line.
C. Administer 1 mg of intramuscular glucagon
A nurse assesses patients for potential endocrine disorders. Which patient is at greatest risk for hyperparathyroidism? a. A 72-year-old male who is prescribed home oxygen therapy b. A 66-year-old female with moderate heart failure c. A 29-year-old female with pregnancy-induced hypertension d. A 41-year-old male receiving dialysis for end-stage kidney disease
D. A 41-year-old male receiving dialysis for end-stage kidney disease
A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first? a. Place the patient in high-Fowler's position and apply oxygen b. Document the finding and assess the patient hourly. c. Reassure the patient that the voice change is temporary. d. Contact the provider and prepare for intubation.
D. Contact the provider and prepare for intubation
A nurse cares for a patient with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? a. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock." 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. "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."
After teaching a patient who is recovering from a complete thyroidectomy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional instruction? a. "I can receive pain medication if I feel that I need it." b. "After surgery, I won't need to take thyroid medication." c. "I'll need to take thyroid hormones for the rest of my life." d. "I may need calcium replacement after surgery."
B. "After surgery, I won't need to take thyroid medication."
An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition? a. Extremity tremors followed by seizure activity b. Increased rate and depth of respiration c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension
B. Increased rate and depth of respiration
An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? a. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. b. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. c. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. d. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels.
B. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. Rationale: An insulin pump provides a small continuous dose of short-duration (rapid- or short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas. Test-Taking Strategy: Focus on the subject, use of an insulin pump. Recalling that short-duration insulin is used in an insulin pump will assist in eliminating options 1 and 2. Noting the word external in the question will assist in eliminating option 3.
A nurse reviews the laboratory results of a patient who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? a. Serum sodium level of 132 mEq (132 mmol/L) b. Serum potassium level of 2.5 mEq/L (2.5 mmol/L) c. Serum calcium level of 8.8 mg/dL (2.2 mmol/L) d. Serum chloride level of 98 mEq/L (98 mmol/L)
B. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
The nurse suspects that a patient is deficient in thyroid-stimulating hormone. What assessment findings would correlate to this condition? (Select all that apply.) a. Hyperactivity b. Weight gain c. Alopecia d. Decreased libido
B. Weight gain C. Alopecia D. Decreased libido
A nurse assesses a patient who has diabetes mellitus and notes that the patient is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the patient's clinical manifestations have not changed. What action would the nurse take next? a. Administer 1 mg of glucagon intramuscularly. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer another half-cup (120 mL) of orange juice d. Administer 10 units of regular insulin subcutaneously.
C. Administer another half-cup (120 mL) of orange juice
A nurse assesses a patient with Cushing's disease. Which assessment findings would the nurse correlate with this disorder? (Select all that apply.) a. Weight loss b. Hypotension c. Muscle atrophy d. Petechiae e. Moon face
C. Muscle atrophy D. Petechiae E. Moon face
A nurse assesses a patient with anterior pituitary hyperfunction. Which clinical manifestations would the nurse expect? (Select all that apply.) a. Barrel-shaped chest b. High-pitched voice c. Protrusion of the lower jaw d. Enlarged hands and feet
A. Barrel-shaped chest C. Protrusion of the lower jaw D. Enlarged hands and feet
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. a. Deep, rapid breathing b. Increased pH c. Elevated blood glucose d. Decreased urine output
A. Deep, rapid breathing C. Elevated blood glucose Rationale: Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid byproducts of fat metabolism, build up and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria. Test-Taking Strategy: Focus on the subject, findings associated with DKA. Recall that the pathophysiology of DKA is the breakdown of fats for energy. The breakdown of fats leads to a state of acidosis. The high serum glucose contributes to an osmotic diuresis. Knowing the pathophysiology of DKA will aid in identification of the correct answer.AC
The nurse is reviewing the health care provider's (HCP's) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the HCP's prescriptions? a. An increased amount of NPH insulin daily insulin b. A decreased-calorie diet c. An increased-calorie diet d. A decreased amount of NPH insulin daily insulin
ANS: A Rationale: Infection is a physiological stressor that can cause an increase in the level of cortisol in the body. An increase in cortisol causes an increase in blood glucose levels. When the client is under stress, such as when an infection is present, an increase in the dose of insulin will be required to facilitate the transport of excess glucose into the cells. The client will not necessarily need an adjustment in the daily diet Test-Taking Strategy: Focus on the subject, care of the client with diabetes mellitus. Noting that the client has an infected foot ulcer will indicate that a stressor is present. Recalling that a stressor increases the client's need for insulin will direct you to the correct option.
The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? a. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." b. "I will stop taking my insulin if I'm too sick to eat." c. "I will decrease my insulin dose during times of illness." d. "I will adjust my insulin dose according to the level of glucose in my urine."
ANS: A Rationale: During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL (14.2 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings. Test-Taking Strategy: Use general medication guidelines to answer the question. Note that options 1, 2, and 3 are comparable or alike and all relate to adjustment of insulin doses.
A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? a. The client needs immediate education before discharge. b. The client's statement is inaccurate, and he or she should be scheduled for outpatient diabetic counseling. c. The client requires follow-up teaching regarding the administration of oral antidiabetics. d. The client's statement is inaccurate, and he or she should be scheduled for educational home health visits.
ANS: A Rationale: If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the HCP should be notified. The client's statement indicates a need for immediate education to prevent hyperosmolar hyperglycemic syndrome (HHS), a life-threatening emergency. Although all of the other options may be true, the most appropriate analysis is that the client requires immediate education. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the subject, client instructions to prevent HHS. Eliminate options that are not immediately threatening. The client requires immediate education.
The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? a. Administer short-duration insulin intravenously. b. Administer 5% dextrose intravenously. c. Apply a monitor for an electrocardiogram. d. Correct the acidosis
ANS: A Rationale: Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action. Test-Taking Strategy: Focus on the client's diagnosis. Note the strategic word, priority. Remember that in DKA, the initial treatment is short- or rapid-acting insulin. Normal saline is administered initially; therefore, option 2 is incorrect. Options 1 and 3 may be components of the treatment plan but are not the priority.
A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. a. Nausea b. Fever c. Confusion d. Bradycardia e. Lethargy f. Tremors
ANS: A, B, C, F Rationale: Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia. Test-Taking Strategy: Focus on the subject, signs and symptoms indicating a complication of hyperthyroidism. Recall that thyroid storm is a complication of hyperthyroidism. Options 3 and 6 can be eliminated if you remember that thyroid storm is caused by the release of thyroid hormones into the bloodstream, causing uncontrollable hyperthyroidism. Lethargy and bradycardia (think: slow down) are signs of hypothyroidism (slow metabolism).
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. a. Feeling cold b. Loss of body hair c. Weight loss d. Persistent lethargy e. Tremors
ANS: A, B, D Rationale: Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism. Test-Taking Strategy: Focus on the subject, signs and symptoms associated with hypothyroidism. Options 1 and 2 can be eliminated if you remember that in hypothyroidism there is an undersecretion of thyroid hormone that causes the metabolism to slow down.
The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? a. Inadequate consumption of nutrients b. Inadequate fluid volume c. Compromised family coping d. Lack of Knowledge
ANS: B Rationale: An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question. Test-Taking Strategy: Note the strategic word, priority, and focus on the data in the question. Use Maslow's Hierarchy of Needs theory. The correct option indicates a physiological need and is the priority. Options 1, 3, and 4 are problems that may need to be addressed after providing for the priority physiological needs.
A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? a. "The best time for me to exercise is mid- to late afternoon." b. "The best time for me to exercise is after breakfast." c. "I should not exercise since I am taking insulin." d. "NPH is a basal insulin, so I should exercise in the evening."
ANS: B Rationale: Exercise is an important part of diabetes management. It promotes weight loss, decreases insulin resistance, and helps to control blood glucose levels. A hypoglycemic reaction may occur in response to increased exercise, so clients should exercise either an hour after mealtime or after consuming a 10- to 15-gram carbohydrate snack, and they should check their blood glucose level before exercising. Option 1 is incorrect because clients with diabetes should exercise, though they should check with their health care provider before starting a new exercise program. Option 3 in incorrect; clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 4 is incorrect; NPH insulin in an intermediate-acting insulin, not a basal insulin. Test-Taking Strategy: Focus on the subject, peak action of NPH insulin. Recalling that NPH insulin peaks at 4 to 12 hours and that exercise is beneficial for clients with diabetes will direct you to the correct option.
The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? a. Unresponsive pupils b. Positive Trousseau's sign c. Negative Chvostek's sign d. Hypoactive bowel sounds
ANS: B Rationale: Hypoparathyroidism is related to a lack of parathyroid hormone secretion or a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit Chvostek's and Trousseau's signs, which indicate potential tetany. The remaining options are not related to the presence of hypocalcemia. Test-Taking Strategy: Focus on the subject, assessment findings associated with hypoparathyroidism and hypocalcemia. Recalling that positive Chvostek's and Trousseau's signs would be noted in this disorder will direct you to the correct option. Also, noting the word positive in the correct option will assist you in answering correctly.
The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the instructions by identifying which method as the best method for monitoring blood glucose levels? a. "I will check my blood glucose level every day at 5:00 p.m." b. "I will check my blood glucose level before each meal and at bedtime." c. "I will check my blood glucose level 2 hours after each meal." d. "I will check my blood glucose level 1 hour after each meal."
ANS: B Rationale: The most effective and accurate measure for testing blood glucose is to test the level before each meal and at bedtime. If possible and feasible, testing should be done during the nighttime hours. Checking the level after the meal will provide an inaccurate assessment of diabetes control. Checking the level once daily will not provide enough data to control the diabetes mellitus. Test-Taking Strategy: Note the strategic word, best. Eliminate options 2 and 3 first because they are comparable or alike. Next, eliminate option 1, knowing that once daily would not be an effective measure for monitoring diabetic control.
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? a. Level of hoarseness b. Respiratory distress c. Hypoglycemia d. Edema at the surgical site
ANS: B Rationale: Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway. Test-Taking Strategy: Note the strategic word, priority. Use the ABCs-airway, breathing, and circulation-to assist in directing you to the correct option.
The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. a. Instruct the client to consume a low-fat diet. b. Encourage the client to consume a well-balanced diet. c. A thyroid-releasing inhibitor will be prescribed. d. Provide a warm environment for the client. e. Instruct the client that episodes of chest pain are expected to occur. f. Instruct the client that thyroid replacement therapy will be needed.
ANS: B, C Rationale: The clinical manifestations of hyperthyroidism are the result of increased metabolism caused by high levels of thyroid hormone. Interventions are aimed at reduction of the hormones and measures to support the signs and symptoms related to an increased metabolism. The client often has heat intolerance and requires a cool environment. The nurse encourages the client to consume a well-balanced diet because clients with this condition experience increased appetite. Iodine preparations are used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. Thyroid replacement is needed for hypothyroidism. The client would notify the health care provider if chest pain occurs because it could be an indication of an excessive medication dose. Test-Taking Strategy: Focus on the client's diagnosis and note the subject, hyperthyroidism. Recalling that in this disorder the client has an increased metabolic rate will assist you in determining the appropriate interventions.
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. a. Polyuria b. Lightheadedness c. Palpitations d. Shakiness e. Fruity Breath
ANS: B, C, D Rationale: Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia.
The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. a. Hot, dry skin b. Irritability c. Nervousness d. Anorexia e. Tremors
ANS: B, C, E Rationale: Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger.
The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. a. Maintain a low-potassium diet. b. Monitor daily weight. c. Assess extremities for edema. d. Maintain a high-sodium diet. e. Monitor intake and output.
ANS: B, C, E Rationale: The client with Cushing's syndrome and a problem of excess fluid volume should be on daily weights and intake and output and have extremities assessed for edema. He or she should be maintained on a high-potassium, low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Test-Taking Strategy: Note the subject, Cushing's syndrome, and focus on the words excess fluid volume to assist in answering the question. Recall that a high sodium intake will contribute to the excess fluid volume. Also, recall that the client with Cushing's syndrome loses potassium. Options 1, 2, and 3 are appropriate interventions for the client with excess fluid volume.
A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? a. Glyburide b. Metformin c. Glucagon d. Regular insulin
ANS: C Rationale: A blood glucose level lower than 50 mg/dL (2.85 mmol/L) is considered to be critically low. Glucagon is used to treat hypoglycemia because it increases blood glucose levels. Insulin would lower the client's blood glucose and would not be an appropriate treatment for hypoglycemia. Glyburide and metformin are oral hypoglycemic agents used to treat type 2 diabetes mellitus and would not be given to a client with hypoglycemia. In addition, an oral medication would not be administered to an unconscious client. Test-Taking Strategy: Focus on the subject, hypoglycemia. Knowing that insulin, glyburide, and metformin are used to treat hyperglycemia will assist in directing you to the correct option.
The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? a. Decreased respiratory rate b. Pedal Edema c. Polyuria d. Diaphoresis
ANS: C Rationale: Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus. Test-Taking Strategy: Focus on the subject, chronic complications of diabetes mellitus. Recall that poor glycemic control contributes to development of the chronic complications of diabetes mellitus. Remember the 3 Ps associated with hyperglycemia—polyuria, polydipsia, and polyphagia.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? a. NPH insulin subcutaneously b. An ampule of 50% dextrose c. IV fluids containing dextrose d. Phenytoin for the prevention of seizures
ANS: C Rationale: Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA. Test-Taking Strategy: Note the strategic word, next. Focus on the subject, management of DKA. Eliminate option 2 first, knowing that short-duration (rapid-acting) insulin is used in the management of DKA. Eliminate option 1 next, knowing that this is the treatment for hypoglycemia. Note the words the serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). This should indicate that the IV solution containing dextrose is the next step in the management of care.
The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? a. To stimulate release of parathyroid hormone b. To treat thyroid storm c. To treat hypocalcemic tetany d. To prevent cardiac irritability
ANS: C Rationale: Hypocalcemia, resulting in tetany, can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes; muscle spasms; or twitching, the health care provider is notified immediately. Calcium gluconate should be readily available in the nursing unit. Test-Taking Strategy: Focus on the subject, the purpose of calcium gluconate. Noting the name of the medication (calcium gluconate) should easily direct you to the correct option. Calcium would be given if hypocalcemia tetany occurs.
The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? a. Pulse b. Respiration c. Temperature d. Blood Pressure
ANS: C Rationale: In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits. Test-Taking Strategy: Note the strategic word, priority. Use knowledge of the normal values of vital signs to direct you to the correct option. The client's temperature is the only abnormal value. Remember that an elevated temperature can indicate an infectious process that can lead to complications in the client with diabetes mellitus.
A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? a. Administer thyroid hormone b. Warm the client c. Maintain a patent airway d. Administer fluid replacement
ANS: C Rationale: Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route. Test-Taking Strategy: Note the strategic word, initially. All the options are appropriate interventions, but use the ABCs-airway, breathing, and circulation-in selecting the correct option.
The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? a. A white blood cell (WBC) count of 6.0 b. A blood glucose level of 110 mg/d c. A potassium (K+) level of 3.0 mEq/L d. A platelet count of 200,000 mm3
ANS: C Rationale: The client with Cushing's syndrome experiences hypokalemia, hyperglycemia, an elevated WBC count, and elevated plasma cortisol and adrenocorticotropic hormone levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids in the body. The laboratory values listed in the remaining options would not be noted in the client with Cushing's syndrome. Test-Taking Strategy: Options 1, 2, and 4 are incorrect because they are within normal ranges and therefore are comparable or alike.
The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? a. "I need to call the health care provider (HCP) because of these symptoms." b. "I need to increase my fluid intake." c. "I need to stop my insulin." d. "I need to monitor my blood glucose every 3 to 4 hours."
ANS: C Rationale: When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones during illness. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Remembering that the type 1 diabetic client needs to take insulin will direct you easily to the correct option.
The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. a. Instruct the client to consume a high-fat diet. b. Provide a cool environment for the client. c. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. d. Instruct the client about thyroid replacement therapy. e. Inform the client that iodine preparations will be prescribed to treat the disorder. f. Encourage the client to consume fluids and high-fiber foods in the diet.
ANS: C, D, F Rationale: The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the HCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. Test-Taking Strategy: Focus on the subject, hypothyroidism. Recalling the manifestations of this disorder and that in this disorder the client has a decreased metabolic rate will assist in determining the appropriate interventions.
