Exam 2

The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? A. "I should look at the condition of my feet every day." B. "I am lucky my shoes fit so nice and tight because they give me firm support." C. "I like when I go out to eat dinner with my husband because I enjoy wearing my high heels." D. "I should only walk barefoot in nice dry weather."

A. "I should look at the condition of my feet every day." Rationale: Footwear Tips for Diabetes Patients include: Avoid shoes with pointed toes. Do not walk barefoot Don't buy shoes with too flat a sole or high heels because they don't allow for even distribution of foot pressure. Look for styles that have soft insoles. Choose leather, canvas, or suede styles to allow adequate circulation of air. Don't buy plastic or other materials that don't allow the shoe to ''breathe." Look for such features as laces, buckles, or Velcro. These make it easier to adjust the shoe. Do not wear shoes that are too tight, it decreases circulation.

A nurse performs discharge teaching for a patient after a left hip arthroplasty using the posterior approach. Which statement indicates teaching is successful? A. "Leg-raising exercises are necessary for several months." B. "I should not try to drive a motor vehicle for 2 to 3 weeks." C. "I will not have any restrictions now on hip and leg movements." D. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

A. "Leg-raising exercises are necessary for several months." Rationale: Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status

The nurse is preparing a teaching plan for a client who had a total left hip replacement. Which interventions should be included in the client's teaching plan? Select all that apply. A. Abduct legs B. Do not cross the legs C. Do not lean forward D. No sitting in a chair at 90 degrees E. Lie on the affected hip when in bed F. Pivot the affected leg/hip when transferring

A. Abduct legs B. Do not cross the legs C. Do not lean forward D. No sitting in a chair at 90 degrees Rationale: When a client has had hip surgery, the hips should be abducted with a pillow placed between the knees. This supports the new hip incision and helps avoid any injury to the site. With hip surgery, the client should not cross the legs. The client has a higher chance of dislocation if he/she did cross the legs. the client should not lean forward, such as tying the shoes or reaching to pick something up off the floor. The affected hip should be supported after surgery to prevent dislocation of the new hip. the client should not sit in a chair at a 90 degree angle - this instruction helps prevent injury to the affected hip. The client should sit in a firm chair and one that is not low to the ground to help prevent injury and dislocation to the new hip incision. The new hip should be supported and instructions should be provided to avoid even minimal injury to the site.

The patient with frostbite on the distal toes of both feet is scheduled for amputation of the damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? A. Arteriogram showing blood vessels B. Peripheral pulse palpation bilaterally C. Patches of black, indurated, cold tissue C. Bilateral pale, cool skin below the ankles

A. Arteriogram showing blood vessels Rationale: Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops, and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.

The nurse is caring for a client with hypothyroidism who receives levothyroxine daily and is scheduled for a procedure under sedation. The nurse contacts the health care provider (HCP) because of the risk of adverse effects when administering which of the ordered medication? A. Benzodiazepine premedication B. Proton pump inhibitor premedication C. Diphenhydramine premed D. Metoclopramide premed

A. Benzodiazepine premedication Rationale: when benzodiazepines are taken with levothyroxine, sedation and respiratory depression can be increased and cause unsafe levels of sedation. Any procedure requiring sedation should be reported to the anesthesia health care provider (HCP) and health care provider (HCP) since this is a common presurgical medication.

When administered long-term, which medication requires ongoing musculoskeletal assessment? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers

A. Corticosteroids Rationale: Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-Blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.

A patient has a plaster cast applied to the right arm for a Colles' fracture. Which nursing action is most appropriate? A. Elevate the right arm on 2 pillows for 24 hours. B. Apply heating pad to reduce muscle spasms and pain. C. Limit movement of the thumb and fingers on the right hand. D. Place arm in a sling to prevent movement of the right shoulder.

A. Elevate the right arm on 2 pillows for 24 hours. Rationale: The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

The nurse receives a client from the recovery room after having a thyroidectomy. What most important interventions will the nurse perform during the next four hours? Select all that apply. A. Keep 10% calcium gluconate available B. Asses back of neck C. Have tracheostomy set-up nearby D. Ambulate within 4 hours E. Assess the clients RR and rhythm

A. Keep 10% calcium gluconate available B. Asses back of neck C. Have tracheostomy set-up nearby E. Assess the clients RR and rhythm

A client had placement of a cast to the right lower extremity 10 minutes ago and is complaining of severe pain and the inability to feel or move the right toes. What should the nurse do immediately? A. Notify the HCP B. Apply cold compression to the client's toes C. Administer pain medication D. Administer BNC oxygen at 2L/m

A. Notify the HCP Rationale: This answer is correct because when a client has placement of a cast and complains of severe pain and the inability to feel or move the right toes, the client is possibly developing compartment syndrome and the health care provider (HCP) must be notified immediately. The cast must be cut off and the client may be taken to surgery to relieve the pressure buildup in the muscles.

A patient with a fracture of the proximal left tibia in a long leg cast reports of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? A. Notify the health care provider immediately. B. Elevate the left leg above the level of the heart. C. Administer prescribed morphine sulfate intravenously. D. Apply ice packs to the left proximal tibia over the cast

A. Notify the health care provider immediately. Rationale: Notify the health care provider immediately of this change in patient's condition, which suggests development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

What is a nursing priority when caring for a patient with hypothyroidism? A. Patient teaching related to levothyroxine B. Providing a dark, low-stimulation environment C. Closely monitoring the patient's intake and output D. precautions related to radioactive iodine therapy

A. Patient teaching related to levothyroxine Rationale: A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine. It is not necessary to closely monitor intake and output. Low stimulation and radioactive iodine therapy are used to treat hyperthyroidism.

A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include: A. Performing sterile pin care as ordered B. Releasing the traction for five minutes each shift C. Elevating the head of the bed 90o D. Loosening the pins if the client complains of headache

A. Performing sterile pin care as ordered Rationale: Nursing care of the client with cervical tongs includes performance of sterile pin care and assessment of the site. The other answers alter the traction and could result in serious injury or death of the client; therefore, they are incorrect.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply. A. Polyuria B. Headache C. Weight gain D. Bone pain

A. Polyuria D. Bone Pain Rationale: The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with Hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain. A headache is not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Scroll down to see the 5 answer choices. A. Preventing unnecessary pressure on the lower limbs B. Turning and repositioning the client at least every 2 hours C. Ensuring that the client has a bowel movement at least once a week D. Keeping the linens wrinkle-free under the client E. Limiting bladder catheterization to once every 12 hours

A. Preventing unnecessary pressure on the lower limbs B. Turning and repositioning the client at least every 2 hours D. Keeping the linens wrinkle-free under the client Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize the risk in these areas.

The nurse is caring for a client who has been given radioactive iodine for the treatment of their hyperthyroidism. The patient vomits after treatment. The nurse knows which important information regarding the emesis from this patient? A. Proceed with caution because the emesis is radioactive B. Clean the emesis immediately as it is a danger to the patient C. This is not a common occurrence and the HCP must be notified immediately D. The patient is fine and there is no immediate danger to the patient or the nurse

A. Proceed with caution because the emesis is radioactive Rationale: The nurse needs to proceed with caution because the emesis is radioactive. Radioactive iodine is irritating to the GI tract and commonly causes vomiting in the patient. The nurses needs to use shielding and radiation precautions.

The nurse is caring for a patient who had a left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? A. Progressive leg exercises to obtain 90-degree flexion B. Early ambulation with full weight bearing on the left leg C. Bed rest for 3 days with the left leg immobilized in extension D. Immobilization of the left knee in 30-degree flexion to prevent dislocation

A. Progressive leg exercises to obtain 90-degree flexion Rationale: The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.

The nurse is providing instruction to a client about iodine for thyroid function. Which food would the nurse recommend as a good source of dietary iodine? A. Shrimp B. unsalted peanuts C. Honey D. Canned fruit

A. Shrimp Rationale: good sources of iodine include shrimp, and other shellfish, iodized salt, cheese, cow milk, eggs, yogurt, iodized salt, saltwater fish, seaweed, and cranberries. Too little iodine may cause the body to not make enough thyroid hormone, which may result in iodine deficiency with enlarged thyroid (Goiter) and signs and symptoms of hypothyroidism.

A client is admitted to the orthopedic unit with an external fixator due to a fractured humerus. Which of these findings should alert the nurse to call the health care provider (HCP) immediately? Select all that apply. A. The client has a temperature of 101.8 degrees F. B. The skin around the insertion site of the fixator is draining green exudate. C. The client's hemoglobin is 7.1 mg/dL D. The client becomes confused, restless with dyspnea. E. The client's WBC count is 9.0 ul

A. The client has a temperature of 101.8 degrees F. B. The skin around the insertion site of the fixator is draining green exudate. C. The client's hemoglobin is 7.1 mg/dL D. The client becomes confused, restless with dyspnea. Rationale: the client's temperature is 101.8F and the first sign of an infection. Infections are the number one complication of external fixators and the health care provider (HCP) must be notified immediately. the client's skin around the external fixator is draining green exudate and this is a major sign of infection at the insertion site. The health care provider (HCP) must be notified immediately of any yellow or green exudate around the insertion site of an external fixator. if a client has a hemoglobin of 7.1 gm/dL, the client is probably losing blood and could go into shock quickly. The health care provider (HCP) must be notified immediately. Hemoglobin of 7 means the client is going to heaven. if the client has a mental status change, becomes confused, restless, has dyspnea, chest pain, or a low pulse ox, the client may have a complication of fat embolism syndrome. This is a medical emergency and the health care provider (HCP) must be notified immediately.

An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? A. Use mirror therapy. B. Give opioid analgesics. C. Rebandage the residual limb. D. Show the patient the leg is gone.

A. Use mirror therapy. Rationale: Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.

The nurse is caring for a client who has undergone subtotal thyroidectomy. Which post-operative assessment should receive the highest priority? A. swallowing reflex B. swelling in lower extremities C. Respiratory rate of 22 b/m D. HR of 98 bpm

A. swallowing reflex Rationale: assessment of a client following a subtotal thyroidectomy includes assessment of anything that could be affected by edema or damage to the laryngeal nerve. The swallowing reflex is the priority to assess following subtotal thyroidectomy. Impaired swallowing may occur related to edema or laryngeal nerve damage that could result from the surgical procedure. Swallowing difficulty related to edema may also affect the airway. The nurse should assess for inspiratory stridor, respiratory difficulty, and hoarseness.

The nurse is providing instructions to a client with a new diagnosis of Graves' Disease who will also receive the prescription methimazole. What instruction will the nurse provide? Select all that apply. A. Take solu-cortef with methimazole daily to reduce adverse effects B. Take methimazole at the same time each day C. Follow-up with clinic for a complete blood count in 4 weeks D. Follow-up with the clinic for laboratory blood test for T3 E. Report fever, chills, or any other symptoms of illness to the physician

B,C,D,E B. Take methimazole at the same time each day C. Follow-up with clinic for a complete blood count in 4 weeks D. Follow-up with the clinic for laboratory blood test for T3 E. Report fever, chills, or any other symptoms of illness to the physician Rationale: The client should be taught to take methimazole at the same time every day. Methimazole works best with a consistent medication level in the blood. Periodic complete blood count tests should be performed to assess for risks associated with taking methimazole, agranulocytosis. The client should be taught to monitor for infection symptoms, such as reporting sore throat and fever. Thyroid studies, including T3 levels, should be checked monthly during initial therapy and every 2-3 months afterwards. The client should be taught the signs and symptoms of hypothyroidism, in case the thyroid hormone is decreased too much. since agranulocytosis is a potential risk with methimazole. Agranulocytosis is a life-threatening immune response. Advising the client to report sore throat, fever, chills, or any other symptoms that could indicate an infection is indicated.

The nurse teaches a patient with diabetes about a healthy eating plan. Which statement made by the patient indicates that teaching was successful? A. "I plan to lose 25 pounds this year by following a high-protein diet." B. "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." C. "I should include more fiber in my diet than a person who does not have diabetes." D. "If I use an insulin pump, I will not need to limit foods with saturated fat in my diet."

B. "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." Rationale: Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes. High-protein diets are not recommended for weight loss.

The nurse is caring for a client with a new diagnosis of Graves' Disease. The nurse analyzes assessment data and determines the client has which of the following physical findings that are characteristic of Graves' Disease? Select all that apply. A. 10 lbs weight gain in 2 months B. Amenorrhea-reposrted 2 periods in 6 months C. Reporting being " hot" all time D. Apical HR 122 E. Bulging of the eyes

B. Amenorrhea-reposrted 2 periods in 6 months C. Reporting being " hot" all time D. Apical HR 122 E. Bulging of the eyes

The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse would determine that there is a need for close observation and a need for follow-up if which is noted? A. Blanching of the nail bed when it is depressed B. Capillary refill greater than 6 seconds C. Palpable pulses distal to the cast D. Sensation when the area distal to the cast is pinched

B. Capillary refill greater than 6 seconds Rationale: To assess for adequate circulation, the nail bed of each finger or toe is depressed until it blanches and then the pressure is released. This is known as capillary refill time. Optimally, the color will change from white to pink rapidly (less than 3 seconds). If this does not occur, the toes or fingers will require close observation and follow-up. Palpable pulses and sensations distal to the cast are expected. However, if pulses could not be palpated or if the client complained of numbness or tingling, the primary health care provider should be notified.

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? A. Recent knee trauma B. Debilitating joint pain C. Repeated knee infections D. Onset of frozen knee joint

B. Debilitating joint pain Rationale: The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? A. 2 × 6 cm right calf abrasion with sanguineous drainage B. Left leg externally rotated and shorter than the right leg C. Stooped posture with a shuffling gait and slow movements D. Mild pain and minimal swelling of the right ankle and foot

B. Left leg externally rotated and shorter than the right leg Rationale: Manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

A patient underwent amputation below the knee on the left leg after a traumatic accident. Which intervention should the nurse include in the plan of care? A. Sit in a chair for 1 to 2 hours three times each day. B. Lie prone with hip extended for 30 minutes 4 times per day. C. Dangle the residual limb for 20 to 30 minutes every 6 hours. D. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

B. Lie prone with hip extended for 30 minutes 4 times per day. Rationale: To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes 3 or 4 times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

How would the nurse explain the process of normal bone remodeling? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are immature bone cells. D. Osteons synthesize organic bone matrix

B. Osteoblasts deposit new bone. Rationale: Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure; however, they are not involved with bone remodeling.

A client in a car accident arrives in the emergency department with a hip dislocation. The nurse places the client in Buck's traction. Which interventions are priority when placing Buck's traction on a client? Select all that apply. A. Keep HOB 45 to 90 degrees at all times B. Perform neuro checks every hour on affected extremity C. Keep weight free hanging at all times with tight traction ropes D. Position pt in side-lying position at all times E. Release free hanging weights on the traction every hour F. Do not elevate HOB over 25 degrees at any time

B. Perform neuro checks every hour on affected extremity C. Keep weight free hanging at all times with tight traction ropes F. Do not elevate HOB over 25 degrees at any time Rationale: A client with Buck's traction should have neurovascular checks every hour while in traction. Neurovascular checks include pulses, motor function, sensation, and capillary refill on the affected limb. Buck's traction, the weights should always be free hanging with tight traction ropes. The weights must not rest on the floor or on the client's bed. The client's HOB should never be elevated over 25 degrees at any time. Raising the HOB higher than 25 degrees decreases the tractions' correct functioning.

A patient presents to the clinical after tripping on a curb and spraining the right ankle. Which initial care measures are appropriate? (Select all that apply.) A. Apply ice directly to the skin. B. Apply heat to the ankle every 2 hours. C. Administer antiinflammatory medication. D. Compress ankle using an elastic bandage. E. Rest and elevate the ankle above the heart. F. Perform passive and active range of motion

C. Administer antiinflammatory medication. D. Compress ankle using an elastic bandage. E. Rest and elevate the ankle above the heart. Rationale: Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

The nurse is caring for a client who underwent thyroidectomy with removal of parathyroid tissue following a diagnosis of thyroid cancer. The nurse notices twitches and spasms along the left lateral facial region. The nurse suspects which adverse outcome of the surgery? A. Hypercalcemia B. Hyperkalemia C. Hypocalcemia D. Spread of cancer to mandibular glands

C. Hypocalcemia Rationale: since the parathyroid glands produce parathyroid hormone, if that hormone is decreased in the bloodstream, so will calcium. Decreased calcium in the body is called hypocalcemia and is defined as serum calcium < 8.8 mg/dL. Symptoms of hypocalcemia include a positive Chvostek's sign or Trousseau's sign, twitches, spasms, muscle weakness, muscular cramping, fatigue, tingling feeling, confusion, and irritability. Treatment is administration of oral or IV calcium, depending on the severity of symptoms.

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? A. Pain B. Left knee stiffness C. Left knee infection D. Left knee instability

C. Left knee infection Rationale: The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

The nurse is completing discharge teaching with a patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? A. Uses an elevated toilet seat. B. Sits with feet flat on the floor. C. Maintains hip in adduction and internal rotation. D. Verifies need to notify future caregivers about the prosthesis.

C. Maintains hip in adduction and internal rotation. Rationale: The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

The nurse is caring for a postoperative client 24 hours following a partial thyroidectomy for persistent hyperthyroidism. What assessment data should the nurse immediately report to the health care provider? A. change on pulse ox from 93% to 91% B. change in RR from 30 to 22 C. change in temp from 99 to 100.2 F D. change in apical HR from 72 to 94 bpm

C. change in temp from 99 to 100.2 F Rationale: the extreme hypermetabolic state of thyroid storm or crisis manifests itself in a high fever and can lead to great energy and oxygen consumption. The client's temperature change from 99 F to 100.2 F indicates a significant change pointing to thyroid storm or crisis. Thyroid crisis or thyroid storm is a hypermetabolic situation that can occur following a partial thyroidectomy. This condition happens suddenly and is caused by excessive thyroid hormone being released into the bloodstream due to manipulation of the thyroid. Immediate action is needed since not treating the client can lead to heart failure. Symptoms are extreme hyperthyroidism symptoms and can become life threatening. Symptoms include a high fever, shaking, extreme tachycardia (over 140 bpm to atrial fibrillation), sweating, and overwhelming restlessness that can lead to unconsciousness. The extreme hypermetabolic rate manifests itself in a high fever and can lead to great energy and oxygen consumption.

A patient who had a long leg cast applied this morning asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? A. "You must ambulate with a physical therapist for the first few days." B. "The cast is not dry yet, so it may be damaged while using crutches." C. "Rest, ice, compression, and elevation are in process to decrease pain." D. "Excess edema and complications are prevented when the leg is elevated for 24 hours."

D. "Excess edema and complications are prevented when the leg is elevated for 24 hours." Rationale: For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. RICE is used for soft tissue injuries, not with long leg casts.

A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? A. "I probably won't be able to play soccer for 6 to 8 months." B. "They will have me do range of motion with my knee soon after surgery." C. "I will need to wear an immobilizer and progressively bear weight on my knee." D. "I can't wait to get this done now so I can play in the soccer tournament next month."

D. "I can't wait to get this done now so I can play in the soccer tournament next month." Rationale: The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. A physical therapist will oversee initial range of motion, immobilization, and progressive weight bearing.

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? A. "I will wash the skin daily under the lamb's wool liner of the vest." C. "I will be careful because the device alters balance." D. "I will drive only during the daytime." E. "I will use a straw for drinking."

D. "I will drive only during the daytime." Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.

An 82-yr-old patient is frustrated by loose abdominal tissue and rigid hips. How should the nurse respond? A. "You should go on a diet and exercise more to feel better about yourself." B. "Something must be wrong with you because you should not have these problems." C. "You have arthritis and need to take nonsteroidal antiinflammatory drugs (NSAIDs)." D. "Decreased muscle mass and strength and increased hip rigidity are expected with aging."

D. Decreased muscle mass and strength and increased hip rigidity are expected with aging." Rationale: The musculoskeletal system's normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient "Something must be wrong with you..." is untrue and will not be helpful to the patient's frustrations.

The nurse determines that an older adult patient recovering from left total knee arthroplasty has impaired physical mobility from decreased muscle strength. What nursing intervention is appropriate? A. Promote vitamin C and calcium intake in the diet. B. Provide passive range of motion to all the joints every 4 hours. C. Keep the left leg in extension and abduction to prevent contractures. D. Encourage isometric quadriceps-setting exercises at least 4 times a day.

D. Encourage isometric quadriceps-setting exercises at least 4 times a day. Rationale: Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures

The patient brought to the emergency department after a car accident is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? A. Administer enoxaparin (Lovenox). B. Provide range-of-motion exercises. B. Apply sequential compression boots. D. Immobilize the fracture preoperatively.

D. Immobilize the fracture preoperatively. Rationale: The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots, not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

In planning the care for a client with Graves Disease, which nursing diagnosis will the nurse select? A. Alteration in Nutrition: More than body requirements related to hypometabolic state B. Impaired gas exchange related to inability to perform activities of daily living w/o oxygen C. self care deficit: Actual related to inability to bathe or dress self D. Impaired tissue integrity: Corneal related to dryness secondary to exophthalmos

D. Impaired tissue integrity: Corneal related to dryness secondary to exophthalmos Rationale: exophthalmos is a cardinal sign of Graves' disease. This bulging of the eye anteriorly from the orbit makes it where the eye lid does not shut completely over the eye. This can cause extreme dryness which can lead to corneal abrasions. Dryness must be treated with lubricating eye drops to decrease corneal abrasions and increase comfort. The drops will supplement lubrication and decrease factors that may lead to lid retraction.

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/VN? A. Assess skin integrity around the traction boot. B. Determine correct body alignment to enhance traction. C. Remove weights from traction when turning the patient. D. Monitor pain intensity and administer prescribed analgesics.

D. Monitor pain intensity and administer prescribed analgesics. Rationale: The LPN/VN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment and should not be delegated or done.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? A. Pain on palpation at the pin sites B. Clear, watery drainage from the pin sites C. Redness around the pin sites D. Thick, yellow drainage from the pin sites

D. Thick, yellow drainage from the pin sites Rationale: The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes

The nurse witnesses a client who fell and sustained a compound fracture to the left arm. Which nursing intervention is the priority to take with this type of fracture? A. wrap the fractured arm with compression bandage B. Attempt to manually reduce the fracture C. Keep the fractured arm below the heart D. Wrap the fracture with a sterile gauze and kerlix

D. Wrap the fracture with a sterile gauze and kerlix Rationale: a compound fracture, the client is at high risk for infection due to environmental exposure. The nurse should wrap the fractured arm in a sterile gauze and kerlix.

A patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? A. "With type 2 diabetes, the body of the pancreas becomes inflamed." B. "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." C. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." D. "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

c. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." Rationale: In type 2 diabetes, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes.

Crutches: correct sequence for climbing stairs includes:

"Up with the Good" 1. Place body weight on crutches 2. advance the unaffected leg (good) onto stairs 3. shift weight from crutches to unaffected leg (good) 4. Bring crutches and the affected led (BAD) up to the stairs

How should the nurse demonstrate going down the stairs with crutches?

"down with the bad" 1. Crutches and affected (BAD) leg down 2. Followed by the unaffected (GOOD) leg

Paralysis from the damaged cellular structures (neurons) in a client with a spinal cord injury may affect: (choose all that apply) A. Mobility B. Sexual function C. Sensation D. Bladder and Bowel function

All are correct! Rationale: Paralysis from the damaged cellular structures (neurons) in a client with a spinal cord injury may affect mobility, sexual function, sensation, and bladder and bowel function.

The nurse prepares to transfer the client with a newly applied leg cast into the bed using which method? A. Supporting the cast with the fingertips only B. Asking the client to support the cast during transfer C. Using the palms of the hands and soft pillows to support the cast D. Placing ice on top of the cast

C. Using the palms of the hands and soft pillows to support the cast Rationale: The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this would be done after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.

The home care nurse observes that the client's supply of levothyroxine has 20 extra doses in the medication bottle. What assessment finding would be most consistent with underuse of the medication levothyroxine? a. constipation and fatigue b. diarrhea and agitation c. tachycardia and weight loss d. exophthalmos and fine tremors e. feeling cold and depressed

a. constipation and fatigue e. feeling cold and depressed

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 - Loss of body hair and feeling cold - Persistent lethargy - Puffiness of the face - Tremors and weight loss

- Loss of body hair and feeling cold - Persistent lethargy - Puffiness of the face Rationale: Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.

The patient with systemic lupus erythematosus is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What interventions should be included in the plan of care? (Select all that apply.) - Obtain daily weights. - Limit fluids to 1000 mL/day. - Administer diuretics as ordered. - Monitor for signs of hypernatremia. - Minimize turning and range of motion. - Elevate the head of the bed at 10 degrees or less.

- Obtain daily weights. - Limit fluids to 1000 mL/day. - Administer diuretics as ordered. - Elevate the head of the bed at 10 degrees or less. Rationale: The care for the patient with SIADH will include limiting fluids to 1000 mL/day or less to decrease weight, increase osmolality, and improve symptoms and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. Measure weights daily and maintain accurate intake and output. Monitor for signs of hyponatremia. Frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

A client has fallen and sustained a leg injury. Which question would the nurse ask to help determine if the client sustained a fracture? A. "Is the pain sharp and continuous?" B. "Does the pain feel like the muscle was stretched?" C. "Is the pain a dull ache?" D. "Does the discomfort feel like a cramp?"

A. "Is the pain sharp and continuous?" Rationale: Fracture pain is generally described as sharp, continuous and increasing in frequency. Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping pain, or soreness. Strains result from trauma to a muscle body or the attachment of a tendon from overstretching or overextension.

which patient with type 1 diabetes would be at the highest risk for developing hypoglycemic unawareness? A. A 58-yr-old patient with diabetic retinopathy B. A 73-yr-old patient who takes propranolol (Inderal) C. A 19-yr-old patient who is on the school track team D. A 24-yr-old patient with a hemoglobin A1C of 8.9%

A 73-yr-old patient who takes propranolol (Inderal) Rationale: Hypoglycemic unawareness is a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.

A nurse is assessing a child suspected of having type 1 diabetes mellitus (DM). Which question should the nurse ask the parents to validate the diagnosis? A. "Does the child have urinary frequency?" B. "Does the child complain of headaches?" C. "Has the child gained a lot of weight?" D. "How much exercise does the child get?"

A. "Does the child have urinary frequency?" Rationale: The 3 P's that the nurse should ask when evaluating a client for DM polydipsia, polyuria, and polyphagia. These terms correspond to increases in thirst, urination, and appetite, respectively.

The nurse teaches a patient recently diagnosed with type 1 diabetes about insulin administration. Which statement by the patient requires an intervention by the nurse? A. "I will discard any insulin bottle that is cloudy in appearance." B. "The best injection site for insulin administration is in my abdomen." C. "I can wash the site with soap and water before insulin administration." D. "I may keep my insulin at room temperature (75° F) for up to 1 month."

A. "I will discard any insulin bottle that is cloudy in appearance." Rationale: Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86° F (30° C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which statement indicates the patient understands teaching about autonomic dysreflexia? A. "I will perform self-catheterization at least 6 times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."

A. "I will perform self-catheterization at least 6 times per day." Rationale: Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization 5 or 6 times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes? A. A 48-yr-old woman with a hemoglobin A1C of 8.4% B. A 58-yr-old man with a fasting blood glucose of 111 mg/dL C. A 68-yr-old woman with a random plasma glucose of 190 mg/dL D. A 78-yr-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL

A. A 48-yr-old woman with a hemoglobin A1C of 8.4% Rationale: Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater.

While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What interprofessional care is appropriate? (Select all that apply.) A. Administer penicillin. B. Administer polyvalent antitoxin. C. Control spasms with diazepam (Valium). D. Teach correct processing of canned foods. E. Provide analgesia with opioids (morphine). F. Prepare for tracheostomy for mechanical ventilation.

A. Administer penicillin. C. Control spasms with diazepam (Valium). E. Provide analgesia with opioids (morphine). F. Prepare for tracheostomy for mechanical ventilation. Rationale: Penicillin is administered to inhibit further growth of Clostridium tetani. Control of the spasms of tetanus is essential because laryngeal and respiratory spasms cause apnea and anoxia. Morphine can be used to manage pain. A tracheostomy is performed early so mechanical ventilation may be done to maintain respirations. Using polyvalent antitoxin and teaching the correct canning process are done for botulism.

A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle would the nurse expect the client to report? A. Amenorrhea B. Menorrhagia C. Metrorrhagia D. Dysmenorrhea

A. Amenorrhea Rationale: Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease. Menorrhagia refers to menstrual periods with abnormally heavy or prolonged bleeding. Metorrhagia refers to uterine bleeding at irregular intervals, particularly between the expected menstrual periods. Dysmenorrhea refers to pain during menstrual periods.

The nurse is assigned to care for a patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in managing diabetes, what should be the nurse's initial intervention? A. Assess patient's perception of what it means to have diabetes. B. Ask the patient to write down current knowledge about diabetes. C. Set goals for the patient to actively participate in managing his diabetes. D. Assume responsibility for all of the patient's care to decrease stress level

A. Assess patient's perception of what it means to have diabetes. Rationale: For teaching to be effective, the first step is to assess the patient. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.

The nurse is managing a client with DKA. Which management intervention is incorrect in the management of a client with DKA? A. Assess potassium levels 2 hours after treatment because potassium shifts affect the heart B. Assess vital signs and monitor ketone levels C. Administer regular insulin as ordered D. Infuse Normal Saline (0.9%) to replace fluid loss

A. Assess potassium levels 2 hours after treatment because potassium shifts affect the heart Rationale: Assessing potassium levels 2 hours after treatment is incorrect as every 2 hours is too long in time. Potassium levels should be monitored, ongoing, as potassium shifts can affect the heart during the DKA episode. Administering regular insulin as ordered and assessing vital signs and monitoring ketone levels are very important in caring a DKA patient.

Which assessment finding would the nurse expect in a patient who has been taking oral prednisone several weeks and is experiencing sudden withdrawal? (Select all that apply.) A. BP 80/50 B. Heart rate 54 C. Glucose 63 mg/dL D. Sodium 148 mEq/L E. Potassium 6.3 mEq/L F. Temperature 101.1° F

A. BP 80/50 C. Glucose 63 mg/dL E. Potassium 6.3 mEq/L F. Temperature 101.1° F Rationale: Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. During acute adrenal insufficiency, the patient exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies, including hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion.

Which assessment finding would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A. Bradycardia Rationale: Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

A patient with type 1 diabetes calls the clinic reporting nausea, vomiting, and diarrhea. It is most important that the nurse advise the patient to: A. Check the blood glucose level every 2 to 4 hours B. Withhold the regular dose of insulin C. Use a less strenuous form of exercise than usual until the illness resolves D. Drink cool fluids with high glucose content

A. Check the blood glucose level every 2 to 4 hours Rationale: If a person with type 1 diabetes is ill, they should test blood glucose levels at least at 2- to 4-hour intervals to determine the effects of this stressor on the blood glucose level.

The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? A. Cheese B. Broccoli C. Chicken D. Oranges

A. Cheese Rationale: Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.

The nurse has been teaching a patient with diabetes how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? A. Chooses a puncture site in the center of the finger pad. B. Washes hands with soap and water to cleanse the site to be used. C. Warms the finger before puncturing the finger to obtain a drop of blood. D. Tells the nurse that the result of 110 mg/dL indicates good control of diabetes.

A. Chooses a puncture site in the center of the finger pad. Rationale: The patient should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client's anxiety? A. Convey empathy, trust, and respect toward the client. B. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening. C. Ignore the signs and symptoms of anxiety, anticipating that they will son disappear. D. Administer a sedative.

A. Convey empathy, trust, and respect toward the client. Rationale: Conveying empathy, trust, and respect toward the client will help the patient to feel comfortable and decrease the anxiety. Giving a sedative is incorrect before the patient has become comfortable. Do not ignore the symptoms of anxiety and talk with your client. Do not use medical terms when a patient is anxious, they will not understand or hear what you are explaining.

A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which priority action should the nurse advise her to take? A. Eat 15 g of simple carbohydrates B. Drink some diet pop C. Take an extra dose of rapid-acting insulin D. Eat a piece of cheese pizza

A. Eat 15 g of simple carbohydrates Rationale: 15 grams of a simple carbohydrate should be taken for symptoms of hypoglycemia. Pizza, diet pop and taking an extra dose of rapid acting insulin is incorrect. Diet sodas increases the risk of diabetes by negatively affecting gut bacteria, insulin secretion, and sensitivity. They also cause blood sugar levels to spike when a person eats carbohydrates, increasing waist circumference and body fat. This can make insulin sensitivity and blood sugar management worse. The final insult brought on by high-fat foods like pizza is the prolonged, gradual blood sugar rise that occurs many hours after eating. And guess what...it's not carbs that are causing the rise. The "rule of 15" is commonly used as a guideline for treatment: After checking your blood glucose level with your meter and seeing that your level is under 70 mg/dl, consume 15 grams of carbohydrate, wait about 15 minutes, then recheck your blood glucose level.

The nurse plans a class for patients who have newly diagnosed type 2 diabetes. Which goal is most appropriate? A. Enable the patients to become active participants in the management of their disease B. Provide the patients with as much information as soon as possible to prevent complications C. Involve the family and significant others in the care of these patients D. Make all patients responsible for the management of their disease

A. Enable the patients to become active participants in the management of their disease Rationale: The goal of diabetes education is to enable the patient to become the most active participant in their own care.

The nurse is assessing a patient newly diagnosed with type 2 diabetes. Which symptom reported by the patient correlates with the diagnosis? A. Excessive thirst B. Gradual weight gain C. Overwhelming fatigue D. Recurrent blurred vision

A. Excessive thirst Rationale: The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.

The nurse is caring for a patient after a parathyroidectomy. The nurse would prepare to administer IV calcium gluconate if the patient has which manifestations? A. Facial muscle spasms and laryngospasms B. Tingling in the hands and around the mouth C. Decreased muscle tone and muscle weakness D. Shortened QT interval on the electrocardiogram

A. Facial muscle spasms and laryngospasms Rationale: Nursing care for a patient after a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g., muscular spasms or laryngospasms develop), IV calcium gluconate should be administered. Mild tetany, characterized by unpleasant tingling of the hands and around the mouth, may be present but should decrease over time without treatment. Decreased muscle tone, muscle weakness, and shortened QT interval are manifestations of hyperparathyroidism.

Which assessment findings in a patient with a thoracic spinal cord injury (T4) would alert the nurse to possible autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Abdominal distention and absence of bowel sounds D. Decreased level of consciousness and hallucinations

A. Headache and rising blood pressure Rationale: Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal problems are not characteristic manifestations.

The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? A. Increased triglyceride levels B. Increased high-density lipoproteins (HDL) C. Decreased low-density lipoproteins (LDL) D. Decreased very-low-density lipoproteins (VLDL)

A. Increased triglyceride levels Rationale: Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

The nurse is caring for a patient receiving high-dose oral corticosteroid therapy after a kidney transplant. Which side effect would the nurse monitor for as it presents the greatest risk? A. Infection B. Low blood pressure C. Increased urine output D. Decreased blood glucose

A. Infection Rationale: Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreasing urine output), hypertension, and hyperglycemia.

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? A. Keep a wrench close or attached to the vest. B. Use the frame and vest to assist in positioning. C. Clean around the pins using betadine swab sticks. D. Loosen both sides of the vest to provide skin care.

A. Keep a wrench close or attached to the vest. Rationale: A halo vest is used to provide cervical spine immobilization while vertebrae heal. There should always be a wrench with the halo vest in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with normal saline or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.

The nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, would perform a complete neurovascular assessment of the affected extremity that includes which interventions. Select all that apply. Scroll down to view all 5 answer choices. A. Level of pain in the affected leg B. Pulse in the affected extremity C. Capillary refill of the affected toes D. Skin color of the affected extremity E. Bilateral lung sounds

A. Level of pain in the affected leg B. Pulse in the affected extremity C. Capillary refill of the affected toes D. Skin color of the affected extremity Rationale: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.

The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of cast. Postoperatively, which nursing assessment is of highest priority to assure client safety? A. Monitoring for blanching ability of toe nail beds B. Monitoring for extremity shortening C. Monitoring for heel breakdown D. Monitoring for bladder distention

A. Monitoring for blanching ability of toe nail beds Rationale: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Which manifestations would represent the expected electrolyte imbalance? (Select all that apply.) A. Nausea and vomiting B. Neurologic irritability C. Lethargy and weakness D. Increasing urine output E. Hyperactive bowel sounds

A. Nausea and vomiting C. Lethargy and weakness D. Increasing urine output Rationale: Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability and hyperactive bowel sounds do not occur with hypercalcemia.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? A. Respirations that are abnormally deep and increased in rate B. Respirations that are abnormally slow C. Respirations that cease for several seconds D. Respirations that are shallow

A. Respirations that are abnormally deep and increased in rate Rationale: Kussmaul's respirations has the pattern of rapid, deep breathing associated with dyspnea. This is the body's attempt to reverse metabolic acidosis through the exhalation of excess CO2, occurring in DKA patients.

A patient is admitted with diabetes, malnutrition, cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result? (Select all that apply.) A. The level is consistent with renal insufficiency from renal nephropathy. B. The level may be high because of dehydration that accompanies hyperglycemia. C. The level may be raised due to metabolic ketoacidosis caused by hyperglycemia. D. The patient may be excreting sodium and retaining potassium from malnutrition. E. This level shows adequate treatment of the cellulitis and acceptable glucose control.

A. The level is consistent with renal insufficiency from renal nephropathy. B. The level may be high because of dehydration that accompanies hyperglycemia. C. The level may be raised due to metabolic ketoacidosis caused by hyperglycemia. Rationale: The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient's potassium level. The increased potassium level does not show adequate treatment of cellulitis or acceptable glucose control.

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder may be developing. Select all that apply. A. Tremors and Confusion B. Fever and Nausea C. Bradycardia D. Lethargy

A. Tremors and Confusion B. Fever and Nausea 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.

Myxedema coma can be precipitated by which of the following? Select all that apply. Scroll down to see the 5 answer choices. A. anesthesia and surgery B. rapid withdrawal of thyroid medication C. hyperthermia D. use of sedatives and opioid analgesics E. acute illness

A. anesthesia and surgery B. rapid withdrawal of thyroid medication D. use of sedatives and opioid analgesics E. acute illness Rationale: Myxedema coma is a rare but serious disorder resulting from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, the use of sedatives and opioid analgesics and hypothermia, not hyperthermia.

Exophthalmos is a common finding among patient with hyperthyroidism. What can the nurse do to help the patient with this condition? Select all that apply. A. encourage the use of dark glasses B. Administer artificial tears for comfort C. Provide a warm blanket D. tape eyelids closed at night if necessary

A. encourage the use of dark glasses B. Administer artificial tears for comfort D. tape eyelids closed at night if necessary Rationale: Exophthalmos is the protrusion of the eyes that can cause dryness and discomfort. Artificial tears can provide local comfort as well as encouraging the use of dark glasses. If the patient cannot sleep because they are unable to close their eyelids the nurse can offer taping the eyelids closed at night, as necessary. Elevating the head of the bed and instructing on a low-salt diet are also important in caring for a patient with exophthalmos. Providing a warm blanket does not help with exophthalmos.

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? A."This medicine is given to help your body respond to stress after removal of the adrenal glands." B. "The medication prevents sodium and water retention after surgery." C. "This drug stimulates your immune system and promotes wound healing." D. "The drug prevent clots from forming in the legs during your recovery from surgery."

A."This medicine is given to help your body respond to stress after removal of the adrenal glands." Rationale: Hydrocortisone is administered IV during and after a bilateral adrenalectomy to ensure adequate responses to the stress of the procedure.

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmoL/L). Which statement by the nurse is best? A."You are at increased risk for developing diabetes." B. "The laboratory test result is positive for type 2 diabetes." C. "The test is normal, and diabetes is not a problem." D. "You will develop type 2 diabetes within 5 years."

A."You are at increased risk for developing diabetes." Rationale: Impaired fasting glucose (fasting blood glucose level between 100 and 125 mg/dL) and impaired glucose tolerance (2-hour plasma glucose level between 140 and 199 mg/dL) represent an intermediate stage between normal glucose homeostasis and diabetes. This stage is called prediabetes, and patients are at increased risk for the development of type 2 diabetes.

Which of the following is not a symptom of hyperglycemia? A.Weight gain B. Polyuria C. Polyphagia D. Polydipsia

A.Weight gain Rationale: Clinical manifestations of hyperglycemia include the 3 P's: polydipsia, polyuria and polyphagia. Weight gain is not a sign of hyperglycemia.

Thyroid storm can be caused by the following: Select all that apply. A. controlled hyperthyroidism B. stress C. manipulation of the thyroid gland during surgery and the release of thyroid hormone into the bloodstream D. severe infection

B,C,D Rationale: Thyroid storm can be caused by manipulation of the thyroid gland during surgery and the release of thyroid hormone into the bloodstream; it also can occur from severe infection and stress. It occurs in client with uncontrollable hyperthyroidism, not controlled hyperthyroidism.

The nurse is teaching a patient with type 2 diabetes how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? A. "Smokeless tobacco products decrease the risk of kidney damage." B. "I can help control my blood pressure by avoiding foods high in salt." C. "I should have yearly dilated eye examinations by an ophthalmologist." D. "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL."

B. "I can help control my blood pressure by avoiding foods high in salt." Rationale: Patients with type 2 diabetes to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with type 2 diabetes need to have a dilated eye examination by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment of retinopathy.

The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the instructions if the patient makes what statement? A. "I should only walk barefoot in nice dry weather." B. "I should look at the condition of my feet every day." C. "I will need to cut back the number of times I shower per week." D. "My shoes should fit nice and tight because they will give me firm support."

B. "I should look at the condition of my feet every day." Rationale: Patients with diabetes need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Routine care includes regular bathing.

The nurse receives a phone call from a patient taking cyclophosphamide for treatment of non-Hodgkin's lymphoma. The patient tells the nurse that she has muscle cramps, weakness, and very little urine output. Which response by the nurse is best? A. "Start taking supplemental potassium, calcium, and magnesium." B. "Stop taking the medication now and call your health care provider." C. "These symptoms will decrease with continued use of the medication." D. "Increase your fluid intake to 3000 mL for 24 hours to improve your urine output."

B. "Stop taking the medication now and call your health care provider." Rationale: Cyclophosphamide may cause syndrome of inappropriate antidiuretic hormone (SIADH). Medications that stimulate the release of ADH should be avoided or discontinued. Treatment may include restriction of fluids to 800 to 1000 mL/day. A loop diuretic such as furosemide (Lasix) is used to promote diuresis, and supplements of potassium, calcium, and magnesium may be needed.

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? A. "I can take the medication with food or milk." B. "The medication should be started 1 week after paralysis." C. "I can take acetaminophen with the prescribed medications." D. "Chances of a full recovery are good if I take the medication"

B. "The medication should be started 1 week after paralysis." Rationale: Prednisone should be started immediately. Patients have the best chance for full recovery if prednisone is initiated before complete paralysis occurs. Prednisone will be tapered over the last 2 weeks of treatment. Oral prednisone may be taken with food or milk to decrease gastrointestinal upset. Patients with Bell's palsy usually begin recovery in 2 to 3 weeks, and most patients have complete recovery in 3 to 6 months. No serious drug interactions occur between prednisone and acetaminophen.

The nurse is caring for a patient recently started on levothyroxine for hypothyroidism. What information reported by the patient requires immediate action? A. Weight gain or weight loss B. Chest pain and palpitations C. Muscle weakness and fatigue D. Decreased appetite and constipation

B. Chest pain and palpitations Rationale: Levothyroxine is used to treat hypothyroidism. With replacement, the patient can be overmedicated, causing hyperthyroidism. Any chest pain, heart palpitations, or heart rate greater than 100 beats/min experienced by a patient starting thyroid replacement should be reported immediately, and electrocardiography and serum cardiac enzyme tests should be performed.

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation? (Select all that apply.) A. Drink milk with each meal. B. Eat 20 to 30 g of fiber per day. C. Use an oral laxative every day. D. Limit intake of caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice. F. Establish bowel evacuation time at bedtime.

B. Eat 20 to 30 g of fiber per day. D. Limit intake of caffeinated beverages. E. Drink 1800 to 2800 mL of water or juice. Rationale: The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Caffeine stimulates fluid loss and can contribute to constipation, so caffeine intake should be limited. Milk also may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless needed. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A 25-yr-old male patient has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? A. Prevent urinary tract infection. B. Encourage him to share his feelings. C. Monitor the patient every 15 minutes. D. Teach him about using the gastrocolic reflex.

B. Encourage him to share his feelings. Rationale: To help the patient with coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages self-expression and verbalization of thoughts and feelings. The patient is at high risk for depression and self-injury because loss of function below the umbilicus is expected. He is a young adult male patient who will need a wheelchair and have impaired sexual function. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits and can make coping difficult. Preventing urinary tract infection and facilitating bowel evacuation with the gastrocolic reflex will be important during recovery. In rehabilitation, monitoring every 15 minutes is not needed unless the patient is on suicide precautions.

The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control within the last 3 months? A. Urine ketone level B. Glycosylated hemoglobin level (HgA1c) C. Prealbumin level D. Fasting glucose level

B. Glycosylated hemoglobin level (HgA1c)

the pateint in the emergency department after a car accident is wearing medical identification listing Addison's disease. What should the nurse expect to be included in the care of this patient? A. Low-sodium diet B. Increased glucocorticoid replacement C. Limiting IV fluid replacement therapy D. withholding mineralocorticoid replacement

B. Increased glucocorticoid replacement Rationale: The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may need large volumes of IV fluid replacement and a high-sodium diet. Withholding mineralocorticoid replacement cannot be done for patients with Addison's disease.

The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? A. Mild to moderate incisional pain B. Laryngeal stridor C. Abdominal cramps D. Difficulty in voiding

B. Laryngeal stridor Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration; stridor is caused by compression of the trachea, leading to respiratory distress. Stridor is an acute emergency situation that requires immediate attention to avoid complete obstruction of the airway. The other answers do not identify signs of a life-threatening complication.

The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include? A. Macroangiopathy only occurs in patients with type 2 diabetes who have severe disease. B. Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin. C. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by most patients with diabetes. D. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control.

B. Microangiopathy most often affects the capillary membranes of the eyes, kidneys, and skin. Rationale: Microangiopathy occurs in diabetes. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.

A patient with diabetes is scheduled for a fasting blood glucose level at 8:00 AM. The nurse teaches the patient to only drink water after what time? A. 6:00 PM on the evening before the test B. Midnight before the test C. 4:00 AM on the day of the test D. 7:00 AM on the day of the test

B. Midnight before the test Rationale: Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.

A patient with diabetes who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? A. Avoid sick people and wash hands. B. Obtain comprehensive dental care. C. Maintain hemoglobin A1C below 7%. D. Coughing and deep breathing with splinting

B. Obtain comprehensive dental care. Rationale: A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.

A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? A. Ask the patient about home insulin doses B. Place the patient on a cardiac monitor C. Start an insulin infusion at 0.1 units/kg/hr D. Administer IV potassium supplements

B. Place the patient on a cardiac monitor Rationale: Placing a patient with DKA on a cardiac monitor must be done first to assess their cardiac rhythm. Starting and insulin infusion and administering IV potassium supplements is next and asking a patient about home insulin doses will be completed at discharge.

A client has had type 2 diabetes for the past 5 years and is admitted for a myocardial infarction. The client is concerned about having another MI and is asking what caused this one. Which would be high priority when discussing diabetes management practices and the risks of another MI? Choose all that apply. A. Determirmining treatment for hypoglycemia B. Reviewing prior blood glucose records C. Reviewing prior blood pressure readings D. Checking foot care practices

B. Reviewing prior blood glucose records C. Reviewing prior blood pressure readings Rationale: Diabetes mellitus and hypertension are common diseases that coexist at a greater frequency than chance alone would predict. Hypertension in the diabetic individual markedly increases the risk and accelerates the course of cardiac disease, peripheral vascular disease, stroke, retinopathy, and nephropathy.

The provider was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? A. White blood cell levels and signs of infection B. Serum calcium levels and signs of hypocalcemia C. Hemoglobin, hematocrit, and red blood cell levels D. Level of consciousness and signs of acute delirium

B. Serum calcium levels and signs of hypocalcemia Rationale: Loss of the parathyroid gland is associated with hypocalcemia. Whereas infection and anemia are not associated with loss of the parathyroid gland, cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? A. 8:40 PM to 9:00 PM B. 9:00 PM to 11:30 PM C. 10:30 PM to 1:30 AM D. 12:30 AM to 8:30 AM

C. 10:30 PM to 1:30 AM Rationale: Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient has a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as: A. central cord syndrome. B. spinal shock syndrome. C. anterior cord syndrome. D. Brown-Séquard syndrome.

B. spinal shock syndrome. Rationale: About 50% of people with acute spinal cord injury develop spinal shock, a temporary loss of reflexes, sensation, and motor activity. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach the patient about self-care? (Select all that apply.) A. Use of antiseizure medications B. Preparing for a nerve block to manage pain C. Administration of corticosteroid medications D. Surgery if conservative therapy is not effective E. Dark glasses and artificial tears to protect the eyes F. A facial sling to support the muscles and facilitate eating

C,E,F C. Administration of corticosteroid medications E. Dark glasses and artificial tears to protect the eyes F. A facial sling to support the muscles and facilitate eating Rationale: Self-care for Bell's palsy includes use of corticosteroid medications to decrease inflammation of the facial nerve (cranial nerve VII). Dark glasses and artificial tears protect the cornea from drying because of the inability to close the eyelid. The occupational therapist may fit a facial sling to support muscles and facilitate eating. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.

The nurse is caring for a client newly diagnosed with Hypothyroidism and teaching about Levothyroxine. The client requires further teaching when they state which of following? A. "Kelp is not good for me when taking this medication." B. "I took my thyroid medication 30 minutes ago, so now I am able to eat." C. "I am glad my breakfast is her so I can take my thyroid medication right before I eat." D. "While I love seafood, I need to make other food choices."

C. "I am glad my breakfast is her so I can take my thyroid medication right before I eat." Rationale: Patients taking thyroid medication need to wait at least 30 minutes before eating a meal. Levothyroxine should be taken daily at the same time. Patient should avoid eating foods with high iodine content such as seafood, kelp, dairy, and iodized salt.

The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? A. "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." B. "I will go running each day when my blood sugar is too high to bring it back to normal." C. "I will take a brisk 30-minute walk 3-5 days per week three times a week." D. "I will plan to keep my job as a teacher because I get a lot of exercise every school day."

C. "I will take a brisk 30-minute walk 3-5 days per week three times a week." Rationale: Taking a brisk 30 minute walk 3-5 days per week is a good exercise for patients with DM. Fishing is not good because the patient is sitting without increasing their heart rate. Working as a teacher does not keep the heart rate elevated for a continuous 30 minutes. Running when the blood sugar is high is not indicated to keep blood sugar levels within normal range.

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she has bowel incontinence 2 or 3 times each day. Which action should the nurse perform first? A. Insert a rectal stimulant suppository. B. Have the patient to gradually increase intake of high-fiber foods. C. Assess bowel movements for frequency, consistency, and volume. D. Teach the patient to avoid all caffeinated and carbonated beverages.

C. Assess bowel movements for frequency, consistency, and volume. Rationale: The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited but need not be eliminated. After stabilization, creation of a bowel program including a rectal stimulant, digital stimulation, or manual evacuation at the same time each day will regulate bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time? A. Routine insulin therapy and exercise B. Administer a different antibiotic for the UTI C. Cardiac monitoring to detect potassium changes D. Administer IV fluids rapidly to correct dehydration

C. Cardiac monitoring to detect potassium changes Rationale: This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.

During the postoperative period, the client who underwent a hip replacement reports pain the calf area. What action would the nurse take? A. Administer as needed (PRN) morphine sulfate as prescribed for postoperative pain B. Lightly massage the calf area to relieve the pain C. Check the calf area for temperature, color, and size D. Ask the client to walk and observe the gait

C. Check the calf area for temperature, color, and size Rationale: The nurse monitors the postoperative client for complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf cold also indicate this complication. Asking the client to walk or massaging the calf could cause a possible thrombosis to break loose resulting in an embolus. Administering pain medication for this client is not the appropriate nursing action since further assessment needs to take place.

The nurse is performing pin-site care on a client in skeletal traction. Which normal finding would the nurse expect to note when assessing the in sites? A. Numbness at the pin sites B. Warm skin around the pin sites C. Clear drainage from the pin sites D. Redness and swelling around the pin sites

C. Clear drainage from the pin sites Rationale: A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Warmth, numbness, redness and swelling around the pin sites may be indicative of an infection.

What should be included in the interprofessional plan of care for a patient with Cushing disease? A. Lab monitoring for hyperkalemia B. Vital sign monitoring for hypotension C. Counseling related to body image changes D. Diet consultation to determine low protein choices

C. Counseling related to body image changes Rationale: Elevated corticosteroid levels can cause body changes, including truncal obesity, moon face, and hirsutism in women and gynecomastia in men. Counseling and support should be offered because of the changes in body image. Hypokalemia and hypertension are consistent with Cushing disease. Sodium restriction and potassium supplementation are indicated. High-protein choices are necessary to counteract catabolic processes and assist with wound healing.

A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which action should the nurse advise the patient to take? A. Eat a piece of pizza. B. Drink some diet pop. C. Eat 15 g of simple carbohydrates. D. Take an extra dose of rapid-acting insulin.

C. Eat 15 g of simple carbohydrates. Rationale: When a patient with type 1 diabetes is unsure about the meaning of the symptoms they are experiencing, they should treat for hypoglycemia to prevent seizures and coma from occurring. Have the patient check the blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease the blood glucose.

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Check for bowel impaction C. Elevate the head of the bed D. Administer intravenous hydralazine

C. Elevate the head of the bed Rationale: Positioning the patient upright is the first action so blood pressure will decrease. Then assessment of indwelling urinary catheter patency or immediate catheterization should be performed to relieve bladder distention. Next, the rectum should be examined for retained stool or impaction. Finally, the nurse will consider administering an intravenous antihypertensive medication if needed.

An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking? A. Weak biceps brachii B. Triceps muscle weakness C. Forearm muscle weakness D. Left leg discomfort

C. Forearm muscle weakness Rationale: Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Weak biceps brachii is not a complication of crutch walking but rather caused by an injury to the brachial plexus itself. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking.

The nurse is caring for a patient with type 1 diabetes who is admitted for diabetic ketoacidosis. The nurse would expect which laboratory test result? A. Hyperphosphatemia B. Hypoglycemia C. Hypokalemia D. Fluid overload

C. Hypokalemia Rationale: Electrolytes are depleted in diabetic ketoacidosis. Osmotic diuresis occurs with depletion of sodium, potassium, chloride, magnesium, and phosphate levels. A patient with diabetic ketoacidosis will be dehydrated (fluid volume deficit), and blood glucose levels would be elevated (hyperglycemia).

When planning care for a patient with a cervical spinal cord injury (C5), which nursing problem has the highest priority? A. Constipation B. Difficulty coping C. Impaired breathing D. Impaired nutritional status

C. Impaired breathing Rationale: Maintaining a patent airway is the most important goal for a patient with a cervical spinal cord injury. Respiratory needs are always the highest priority (ABCs).

The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection? A. Dependent edema B. Diminished distal pulse C. Presence of warm areas on the cast D. Coolness and pallor of the skin

C. Presence of warm areas on the cast Rationale: Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.

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 continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. C. 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. D. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals.

C. 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.

A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information would the nurse provide to the client to prevent complications? A. Trim the rough edges of the cast after it is dry B. Expect burning and tingling sensations under the cast for 3 to 4 days C. Keep the right ankle elevated above the heart level with pillows for 24 hours D. Weight bearing on the right leg is allowed once the cast feels dry

C. Keep the right ankle elevated above the heart level with pillows for 24 hours Rationale: Leg elevation is important to increase venous return and decrease edema. Edema can cause compartment syndrome, a major complication of fractures and casting. The client and/or family may be taught how to 'petal' the cast the prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in the skin integrity. Weight bearing on a fractured extremity is prescribed by the primary health care provider during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. The complaints should be reported immediately.

A patient, admitted with diabetes, has a glucose level of 580 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? A. Central apnea B. Hypoventilation C. Kussmaul respirations D. Cheyne-Stokes respirations

C. Kussmaul respirations Rationale: In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.

The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to explain how this medication works? A. Increases insulin production from the pancreas. B. Slows the absorption of carbohydrate in the small intestine. C. Reduces glucose production by the liver and enhances insulin sensitivity. D. Increases insulin release from the pancreas and inhibits glucagon secretion.

C. Reduces glucose production by the liver and enhances insulin sensitivity. Rationale: Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue's insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? A. Pain assessment B. Glasgow Coma Scale C. Respiratory assessment D. Musculoskeletal assessment

C. Respiratory assessment Rationale: Although all the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure requires vigilant monitoring of the patient's respiratory function.

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. Edema at the surgical site C. Respiratory distress D. Hypoglycemia

C. Respiratory distress 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.

Which of the following methods would be the preferred method to use when performing physical assessment (palpation) of the thyroid gland? A. Stand behind the client, place the fingers above the jugular notch, have the client extend the head and swallow B. Stand in front of the client, place fingers slightly above the thyroid cartilage, have the client extend the head and swallow C. Stand behind the client, place the fingers on either side of the trachea below the thyroid cartilage, have the client tilt the head to the right and swallow D. Stand in front of the client, place fingers above the trachea, have the client flex the head, and ask the client to swallow

C. Stand behind the client, place the fingers on either side of the trachea below the thyroid cartilage, have the client tilt the head to the right and swallow Rationale: Standing behind the client, place the fingers on either side of the trachea below the thyroid cartilage, have the client tilt the head to the right and swallow is the correct way to assess the patients thyroid.

A patient who smokes reports having significant stress and has some eye problems. On assessment, the nurse notes exophthalmos. What additional abnormal findings should the nurse assess for? A. Muscle weakness and slow movements B. Puffy face, decreased sweating, and dry hair C. Systolic hypertension and increased heart rate D. Decreased appetite, increased thirst, and pallor

C. Systolic hypertension and increased heart rate Rationale: The manifestations are consistent with Graves' disease or hyperthyroidism. Systolic hypertension, increased heart rate, and increased thirst are associated with hyperthyroidism. Cigarette smoking places the patient at increased risk for Graves' disease. The inhaled cigarette toxins may absorb via the eye orbits, causing exophthalmos. A puffy face; decreased sweating; dry, coarse hair; muscle weakness and slow movements; decreased appetite; and pallor are all manifestations of hypothyroidism.

The nurse gives corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? A. The patient's lung sounds are clear B. The patient's urinary output decreases C. The patient is alert and oriented D. The patient's potassium level is 5.7 mEq/L

C. The patient is alert and oriented Rationale: The patient in acute adrenal insufficiency will have the following clinical manifestations: hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative care will include administration of corticosteroids. An outcome that would indicate patient improvement would be improved level of consciousness (i.e., alert and oriented).

The nurse is caring for a patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed? A. The patient supports her head when moving in bed B. The patient reports a sore throat when swallowing C. The patient makes harsh, vibratory sounds when breathing D. The patient reports of increased thirst

C. The patient makes harsh, vibratory sounds when breathing Rationale: After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). Emergency equipment should be at the bedside, including oxygen, suction equipment, and a tracheostomy tray.

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120mg/dL. The nurse will first plan to teach the patient about _____. A. effects of oral hypoglycemic medications B. self-monitoring of blood glucose C. lifestyle changes to lower blood glucose D. using low doses of regular insulin

C. lifestyle changes to lower blood glucose Rationale: Teaching the client about lifestyle changes to lower blood glucose is the first topic to be taught so it can be evaluated for a possible change at the next visit. In a pre-diabetic patient we do not begin self-monitoring of blood glucose or give medications until diabetes mellitus is diagnosed and uncontrolled.

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 monitor my blood glucose every 3 to 4 hours." C. "I need to increase my fluid intake." D. "I need to stop my insulin."

D. "I need to stop my insulin." Rationale: Insulin should never be stopped immediately. Without insulin, the body cannot access enough sugar to function properly, so your liver begins to turns some of the body fat into acids called ketones. These build up in the bloodstream and spill over into the urine.

The nurse is teaching a patient with type 2 diabetes about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? A. "I will go running when my blood sugar is too high to lower it." B. "I will go fishing frequently and pack a healthy lunch with plenty of water." C. "I do not need to increase my exercise routine since I am on my feet all day at work." D. "I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week."

D. "I will take a brisk 30-minute walk 5 days/wk and do resistance training 3 times a week." Rationale: The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days/wk and resistance training 3 times a week. Brisk walking is moderate activity. Fishing and walking at work are light activity, and running is considered vigorous activity.

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? A. "I want to be rehabilitated for my daughter's wedding in 2 weeks." B. "Rehabilitation will be more work done by me alone to try to get better." C. "I will be able to do all my normal activities after I go through rehabilitation." D. "With rehabilitation, I will be able to function at my highest level of wellness."

D. "With rehabilitation, I will be able to function at my highest level of wellness." Rationale: Rehabilitation is an interprofessional endeavor to teach and enable the patient to function at their highest level of wellness and adjustment. Intense work will be required of all involved persons; the process will take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to perform all normal activities at the same level as previously.

A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in determining a diagnosis for this patient? A. Administration of β-blocker medications B. Abdominal palpation to search for a tumor C. Administration of potassium-sparing diuretics D. A 24-hour urine collection for fractionated metanephrines

D. A 24-hour urine collection for fractionated metanephrines Rationale: Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma, an α-adrenergic receptor blocker is used preoperatively to reduce blood pressure. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed. Most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

The nurse caring for a patient hospitalized with diabetes would look for which laboratory test result to obtain information on the patient's past glucose control? A. Prealbumin level B. Urine ketone level C. Fasting glucose level D. Glycosylated hemoglobin level

D. Glycosylated hemoglobin level Rationale: A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.

In a client with Graves Disease, which clinical manifestation would the nurse expect a client to report? A. Bradycardia B. Lethargy C. Cold, clammy skin D. Heat Intolerance

D. Heat Intolerance Rationale: Common signs and symptoms of Graves' disease include: Anxiety and irritabilityA fine tremor of the hands or fingersHeat sensitivity/intolerance and an increase in perspiration or warm, moist skinWeight loss, despite normal eating habitsEnlargement of the thyroid gland (goiter)Change in menstrual cyclesErectile dysfunction or reduced libidoFrequent bowel movementsBulging eyes (Graves' ophthalmopathy)FatigueThick, red skin usually on the shins or tops of the feet (Graves' dermopathy)Rapid or irregular heartbeat (palpitations)Sleep disturbance

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. Warm the client B. Administer IV thyroid hormone replacement C. Administer fluid replacement D. Maintain a patent airway

D. Maintain a patent airway Rationale: Myxedema coma is a medical emergency an is characterized by subnormal temperature, hypotension and hypoventilation. Cardiovascular collapse can results from hypoventilation. For the patient to survive myxedema coma, vital functions must be supported and maintaining a patent airway is initially, priority. Administering IV thyroid hormone replacement and fluids must also take place after airway is maintained. Lastly, assure the client is warmed.

The patient with an adrenal hyperplasia is returning from surgery after an adrenalectomy. The nurse should monitor the patient for what immediate postoperative complication? A. Vomiting B. Infection C. Thromboembolism D. Rapid blood pressure changes

D. Rapid blood pressure changes Rationale: The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

The nurse is caring for a patient with hypothyroidism. The patient states they have been taking their thyroid medication as prescribed but states they are now experiencing fatigue, brittle nails, dry hair, dry skin and feeling cold. They also share they have 10 pounds of unexplained weight gain. The nurse suspects which of the following? A. The patient is exaggerating and needs to be told this is normal B. The patient may need to stop taking their medication C. The patient is not telling the truth about taking their medication as prescribed D. The patient may need an adjustment in their medication

D. The patient may need an adjustment in their medication Rationale: Occasionally, patient may need an adjustment in their medication. These clinical manifestations should be reported to the HCP. An increase in their medication is needed and will be ordered by the HCP. These clinical manifestations improve significantly after 3 months of taking their thyroid medication of the appropriate dose and should only return during an exacerbation of the condition.

The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction? A. Complaints of leg discomfort B. Toes are warm and demonstrate a brisk capillary refill C. Drainage at the pin sites D. Weak pedal pulses

D. Weak pedal pulses Rationale: Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.

The nurse is checking the laboratory results of an adult client with type 1 diabetes (see below). What laboratory result indicates a problem that should be managed? - Blood glucose: 192mg/dL - Total cholesterol: 201 mg/dL - Hemoglobin: 12.3 mg/dL - Low-density lipoprotein (LDL) E. cholesterol: 125 mg/dL A. total cholesterol B. hemoglobin C. low-density lipoprotein (LDL) cholesterol D. blood glucose

D. blood glucose The normal range for blood glucose is 70 to 110 mg/dL; the elevated blood glucose level indicates hyperglycemia. The other results are within normal limits.

Describe how diabetic ketoacidosis could develop in a patient with Type 1 DM, who has undergone surgery

In a patients with Type I DM who have surgery, they may experience extra stress in the body or could be developing an infection, which would cause ketoacidosis.

Thyroid storm is an acute and life-threatening condition that occurs in clients with uncontrollable hyperthyroidism. - True - False

True. Rationale: Thyroid storm is an acute and life-threatening condition that occurs in clients with uncontrollable hyperthyroidism.