final exam review 2139
After receiving change-of-shift report about the following four clients, which client should the nurse assess first? 70-year-old returning from PACU following partial thyroidectomy who is extremely agitated, has an irregular pulse rate of 134, and an elevated temperature of 103.2°F (39.6°C) 53-year-old who has Addison disease and is due for a scheduled dose of hydrocortisone 31-year-old who has iatrogenic Cushing syndrome with a capillary blood glucose level of 204 mg/dL (11.32 mmol/L) 22-year-old admitted with SIADH who has a serum sodium level of 130 mEq/L (130 mmol/L)
70-year-old returning from PACU following partial thyroidectomy who is extremely agitated, has an irregular pulse rate of 134, and an elevated temperature of 103.2°F (39.6°C) Explanation: Manipulation of a hyperactive thyroid gland during thyroidectomy can cause thyroid storm. It is manifested by very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium). The 22-year-old has normal sodium levels. The 31-year old has a high blood glucose level but not at a critical level. The medication schedule for the 53-year-old is lower priority. It is always preferred to give medications in timely manner; however, thyroid storms are the priority for this group of clients.
Which client requires the most rapid attention by the emergency department nurse? A client with symptoms of fatigue, fever, headache, and an erythrocyte sedimentation rate (ESR) of 15 mm/hour A client with thrombocytopenia who has oozing from an IV site A neutropenic client with a temperature of 101.8°F (38.8°C) A client with a rash and elevated basophils
A neutropenic client with a temperature of 101.8°F (38.8°C) Explanation: Neutrophils provide the first line of defense against organisms that inhabit the skin and gastrointestinal tract. Thus, early signs of infection due to neutropenia, particularly those associated with a mild to moderate decrease in neutrophils, include mild skin lesions, stomatitis, pharyngitis, and diarrhea. Signs and symptoms of more severe neutropenia include malaise, chills, and fever, followed in sequence by marked weakness and fatigability. Untreated infections can be rapidly fatal, particularly if the ANC drops below 250/μL. Therefore, this client is at highest risk and should be seen prior to the other clients.
After a long bout with vomiting and diarrhea, a client is suspected to be in hypovolemic shock. Which clinical manifestations will the nurse assess that substantiates this diagnosis? Select all that apply. Apprehension Warm, dry skin Acidosis Tachycardia Slow, shallow respiration
Acidosis Tachycardia Apprehension Explanation: A client in hypovolemic shock will have reflex tachycardia, which attempts to compensate for the fall in cardiac output. Skin will be cool and clammy as peripheral blood vessels constrict to shunt blood to vital organs. Metabolic acidosis arises as body cells switch to anaerobic metabolism. Rapid, deep respiration is a response to acidosis. Apprehension results from cerebral hypoxia.
Question 20 A nurse is caring for a pregnant client with sickle cell anemia. What should the nursing care for the client include? Select all that apply. Teach the client meticulous handwashing. Instruct the client to consume protein-rich food. Assess serum electrolyte levels of the client at each visit. Assess hydration status of the client at each visit. Urge the client to drink 8 to 10 glasses of fluid daily.
Assess hydration status of the client at each visit. Urge the client to drink 8 to 10 glasses of fluid daily. Teach the client meticulous handwashing. Explanation: The nurse caring for a pregnant client with sickle cell anemia should teach the client meticulous handwashing to prevent the risk of infection, assess the hydration status of the client at each visit, and urge the client to drink 8 to 10 glasses of fluid daily. The nurse need not assess serum electrolyte levels of the client at each visit or instruct the client to consume protein-rich food.
Question 24 of 66 The nurse begins administering blood to a pediatric client with hemoglobinopathy. During the transfusion, the nurse notes: a rash on the child's chest, face, and extremities; temperature 101.8°F (38.8°C); respirations 34 breaths/minute; and the child reports nausea. Which actions will the nurse take? Select all that apply. Assess the child's vital signs. Administer only IV normal saline (NS). Monitor the child's urine output. Call the child's primary health care provider. Stop the blood transfusion.
Assess the child's vital signs. Administer only IV normal saline (NS). Monitor the child's urine output. Call the child's primary health care provider. Stop the blood transfusion. Explanation: Based on the findings, the nurse would suspect an adverse reaction to the blood transfusion. The nurse would immediately stop the transfusion, administer NS IV to the client, send the blood and tubing to the laboratory, and notify the health care provider. The nurse would continue to monitor the child by assessing vital signs and monitor urine output as a decrease in kidney function could indicate acute kidney failure.
A client should be educated to limit consumption of which of the following foods to prevent an exaggerated sympathetic-type response when taking isoniazid (INH) for the treatment of tuberculosis? Select all that apply. Alcohol Grapes Bananas Meats Broccoli
Bananas Meats Alcohol Explanation: When isoniazid is taken with foods containing tyramine, such as aged cheese and meats, bananas, yeast products, and alcohol, an exaggerated sympathetic-type response can occur.
A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client? Blood urea nitrogen (BUN) 15 mg/dl Arterial pH 7.25 Plasma bicarbonate 12 mEq/L Blood glucose level 1,100 mg/dl
Blood glucose level 1,100 mg/dl Explanation: HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.
A client who is pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she is apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing: back labor. true labor contractions. Braxton Hicks contractions. fetal distress.
Braxton Hicks contractions. Explanation: Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. Back labor refers to labor pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green-tinged fluid, or port-wine-colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern.
A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? Isolation until 24 hours after antitubercular therapy begins Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years Daily doses of isoniazid, 300 mg for 6 months to 1 year Nothing, until signs of active disease arise
Daily doses of isoniazid, 300 mg for 6 months to 1 year Explanation: All clients exposed to persons with tuberculosis should receive prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium. Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with active tuberculosis. Isolation for 2 to 4 weeks is warranted for a client with active tuberculosis.
Question 18 The nurse is assessing a child with aplastic anemia. Which findings are anticipated? Select all that apply. ecchymoses Tachycardia Guaiac-positive stool Epistaxis Severe pain Warm tender joints
Ecchymoses Tachycardia Guaiac-positive stool Epistaxis Explanation: Assessment findings associated with aplastic anemia include ecchymoses, epistaxis, guaiac-positive stools, and tachycardia. Severe pain and warm tender joints are most often associated with sickle cell crisis. Reference: Chapter 46: Nursing Care of the Child With an Alteration in Cellular Regulation/Hematologic or Neoplastic Disorder - Page 1710
Question 23 A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply. Fever Facial flushing Low back pain Urticaria Hematuria
Fever Facial flushing Low back pain Hematuria Explanation: Symptoms of a hemolytic reaction, which are immediate, include facial flushing, fever, chills, headache, low back pain, tachycardia, dyspnea, hypotension, and blood in the urine. Urticaria is seen with an allergic reaction.
A laboring woman with a history of a previous cesarean birth suddenly begins to exhibit manifestations of hypovolemic shock. Suspecting either complete or partial uterine rupture, which priority interventions should the nurse implement first? Select all that apply. Weigh all the blood-saturated bandages to determine amount of blood loss. Prepare to administer epinephrine directly into the uterine muscle. Prepare to administer IV oxytocin to assist with uterine contraction. Increase IV fluids immediately. Call respiratory therapy to obtain ABGs.
Increase IV fluids immediately. Prepare to administer IV oxytocin to assist with uterine contraction. Explanation: Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an immediate emergency. The nurse should administer emergency fluid replacement therapy as prescribed and anticipate the use of IV oxytocin to attempt to contract the uterus and minimize bleeding. ABGs are not the priority. Epinephrine is not given by direct injection into a muscle but by IV infusion during a code to cause vasoconstriction, thereby increasing BP. Blood loss will be estimated. Weighing saturated bandages is not the priority.
A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply. Offer to pray with the family if appropriate. Initiate spiritual comfort by calling the hospital clergy, if appropriate. Leave the parents to talk through their next steps. Advise the parents that the hospital can make the arrangements. Respect variations in the family's spiritual needs and readiness.
Offer to pray with the family if appropriate. Initiate spiritual comfort by calling the hospital clergy, if appropriate. Respect variations in the family's spiritual needs and readiness. Explanation: When assisting the parents to cope with a perinatal loss, the nurse must respect variations in the family's spiritual needs and readiness. The nurse will also initiate spiritual comfort by calling the hospital clergy, if appropriate, and can offer to pray with the family, if appropriate.
The nurse is caring for a client with sepsis who has developed disseminated intravascular coagulation (DIC). Which assessments should the nurse prioritize? Select all that apply. Oxygen saturation Urine output Level of consciousness Weight Platelet count
Oxygen saturation Urine output Level of consciousness Explanation: The priority risk during DIC is multiple organ failure due to microthrombi or hypovolemic shock. The client has already been diagnosed with DIC so assessing the platelet count now is not a priority for the nurse compared to assessing the client's organ function. Signs of organ failure include a drop in oxygen saturation, decreased urine output, and altered level of consciousness. Weight is not a priority related to organ failure.
Following a cesarean birth, what should the nurse do first? Check the abdominal dressing. Palpate the fundus. Observe the amount of lochia. Obtain blood pressure and pulse.
Palpate the fundus. Explanation: Every postpartum client, regardless of the type of birth, is at risk for uterine atony and hemorrhage, and following childbirth, the nurse should first palpate the fundus to determine if there is uterine atony. Even though an abdominal incision and abdominal dressing are present, the nurse should palpate the fundus gently while supporting the incision every 15 minutes for at least 1 hour, more frequently if vaginal bleeding is moderate or severe and if the fundus is soft or boggy. Although the nurse also should observe and note any bleeding on the abdominal incision dressings, the priority is to determine uterine atony. After palpating the fundus to determine uterine tone, the nurse can then note the amount of lochia immediately after childbirth and during the recovery period. The nurse should first determine if there is uterine atony and then obtain vital signs every 15 minutes during the first hour. Changes in vital signs such as hypotension and tachycardia may be late signs of hypovolemic shock due to hemorrhage.
A client with heart failure is prescribed to receive 2 units of packed red blood cells. Which actions will the nurse take to decrease the client's risk of developing transfusion-associated circulatory overload? Select all that apply. Place feet in a dependent position Reduce the rate of transfusion to 100 mL/hr Provide furosemide as prescribed before the transfusion Restrict the intake of oral fluids Elevate the head of the bed
Place feet in a dependent position Reduce the rate of transfusion to 100 mL/hr Provide furosemide as prescribed before the transfusion Elevate the head of the bed Explanation: Transfusion-associated circulatory overload (TACO) can be aggravated in clients who already have increased circulatory volume such as heart failure. For clients who are at risk for or already in circulatory overload, diuretics are given prior to the transfusion. The rate of transfusion may need to be decreased to less than 100 to 120 mL/hr. If the overload is severe, the client is placed upright with the feet in a dependent position. Restriction of oral fluids is not identified as an action to prevent or treat the symptoms of TACO.
The nurse is caring for a client who has a positive tuberculin test. The client has close contact with family members who have active tuberculosis (TB), but the client does not have active TB (per negative x-ray). Which treatment is most appropriate for the client? Prophylactic treatment with isoniazid Treatment with three antituberculosis medications: rifampin, isoniazid, and pyrazinamide Surgical removal of the tuberculosis-infected lung No medical treatment is required
Prophylactic treatment with isoniazid Explanation: The person has been exposed to TB but does not have active TB (per negative x-ray). In addition to persons with active tuberculosis, persons who have had contact with cases of active tuberculosis and who are at risk for development of an active form of the disease are treated. Prophylactic treatment is also used for persons who have latent tuberculosis infection but do not have active disease. These persons are considered to harbor a small number of microorganisms and usually are treated with isoniazid.
Question 54 A nurse is caring for an 18-month-old child 24 hours after surgery to repair a fractured tibia. Which comfort interventions are appropriate? Select all that apply. Reposition the child as often as needed. Let the child play with a favorite toy. Allow the child's family to participate in care as much possible. Explain actions to the child prior to carrying them out. Give pain medication every 4 hours. Provide a rocking chair for the parent to hold the child.
Provide a rocking chair for the parent to hold the child. Reposition the child as often as needed. Let the child play with a favorite toy. Allow the child's family to participate in care as much possible. Explain actions to the child prior to carrying them out. Explanation: Frequent repositioning helps decrease discomfort and gives the nurse an opportunity to assess for changes in status. Infants and children derive comfort and security from playing with a favorite toy or animal. Such play should be encouraged as long as it's permitted. Familiarity is a positive force with children, and parents should be encouraged to participate in their child's care. The nurse should explain her actions to the child. Although the child may not understand each event, it's better for the nurse to provide an explanation than leave the child fearful of what might happen. A rocking chair is a way for the parent to hold and soothe the child. Pain medications should not be given unless needed.
The nurse caring for a group of older adults is reviewing medical records for factors that might increase the risk for falls. Which conditions increase the risks? Select all that apply. Taking a thyroid preparation History of gouty arthritis Receiving a daily diuretic Climbing on chairs to reach items in cabinet Bilateral untreated cataracts
Receiving a daily diuretic Climbing on chairs to reach items in cabinet Bilateral untreated cataracts Explanation: Older adults with respiratory conditions might experience syncope and a fall from cerebral hypoxia. Musculoskeletal conditions such as rheumatoid arthritis or osteoarthritis contribute to falls by causing impaired mobility. Neurologic conditions contribute to falls through impaired mobility and judgment. Visual impairment contributes to falls when people are unable to see. Medications that commonly contribute to falls are those that reduce mental alertness or blood pressure. Diuretics can create a dual risk if the client experiences a feeling of urgency along with the possibility of dehydration or hypovolemia, which could affect their blood pressure (hypotension).
Which clinical manifestations following thyroidectomy would alert the nurse that the client is going into a life-threatening thyroid storm? Select all that apply. Temperature of 104.2°F (40.1°C) Unable to close eyelids completely together Extremely agitated Telemetry showing heart rate of 184 Bruising on knees and feet
Telemetry showing heart rate of 184 Temperature of 104.2°F (40.1°C) Extremely agitated Explanation: Thyroid storm, or crisis, is an extreme and life-threatening form of thyrotoxicosis, rarely seen today. When it does occur, it is seen most often in undiagnosed cases or in persons with hyperthyroidism that has not been adequately treated. It often is precipitated by stress such as an infection, diabetic ketoacidosis, physical or emotional trauma, or manipulation of a hyperactive thyroid gland during thyroidectomy. It is manifested by a very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium).
The nurse is caring for several clients. Which clients could the nurse anticipate being candidates to receive colony stimulating factors? Select all that apply. The client diagnosed with leukocytosis and fever The client with late stage chronic kidney disease The client being treated with chemotherapy for cancer The client being treated with high dose corticosteroids The client diagnosed with acquired immunodeficiency syndrome (AIDS)
The client with late stage chronic kidney disease The client being treated with chemotherapy for cancer The client diagnosed with acquired immunodeficiency syndrome (AIDS) Explanation: Colony stimulating factors are used to stimulate the growth of certain blood cell lines, including white blood cells (granulocyte-stimulating factor), red blood cells (erythropoietin), and platelets (thrombopoietin). They are used treat bone marrow failure caused by chemotherapy, anemia of kidney failure, and in AIDS. Leukocytosis (elevated white blood cell count) and fever are indications of bacterial infection and would not be treated with colony-stimulating factors. Being treated with corticosteroids does not result is bone marrow failure and would not be an indication for colony-stimulating factors.
The nurse is examining a child with hypoparathyroidism. The nurse would expect to assess which signs and symptoms? Select all that apply. capillary refill Babinski sign polyphagia Trousseau sign Chvostek sign
Trousseau sign Chvostek sign Explanation: A child with hypoparathyroidism would have a positive Chvostek or Trousseau sign, both of which indicate hypocalcemia. To test for the Chvostek sign, tap sharply over the facial nerve below the temple and anteriorly to the ear. The sign is positive when the mouth twitches (contraction of the lateral facial muscles). To check for the Trousseau sign, apply a blood pressure cuff to the child's upper arm. Inflate the cuff until the blood supply is occluded. If doing so causes carpal spasm (the fingers contract and the child is unable to open the hand), the Trousseau sign is positive. Capillary refill helps to evaluate tissue oxygenation. Polyphagia refers to excessive eating or hunger. Babinski refers to the Babinski reflex, which suggests neurologic dysfunction.
Hypovolemic shock is characterized by a loss of blood volume or extracellular fluid. Administering which of the following would manage a client with hypovolemic shock? Select all that apply. Plasma volume expanders Packed red blood cells Vasoconstrictor drugs Whole blood Crystalloids
Whole blood Crystalloids Plasma volume expanders Packed red blood cells Explanation: The objective in managing hypovolemic shock is to restore blood volume. Whole blood or packed red blood cells can be administered. Crystalloids such as isotonic saline or Ringer's lactate provide a temporary volume increase. Plasma expanders, such as colloidal albumin or pentastarch, have a longer duration of action. The use of vasoconstrictor drugs is controversial: many vascular beds are already constricted in response to hypovolemia. Further vasoconstriction can be harmful
The nurse is caring for a client during the first 72 hours after thyroidectomy. The nurse should assess for which signs of complications of this surgery? confusion and headache muscle weakness and atrial fibrillation carpal spasms and facial numbness bradycardia and nausea
carpal spasms and facial numbness Explanation: A client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal of or damage to the parathyroid gland. The client with hypocalcemia may exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes), facial numbness and tingling (especially of the lips and around the mouth), laryngeal spasms, and ventricular dysrhythmias. Confusion and headache would be associated with hyponatremia. Bradycardia and nausea would be associated with hypercalcemia. Muscle weakness and atrial fibrillation are seen with hypermagnesemia.
A nurse is teaching the parents of a child with sickle cell disease. The nurse determines that the teaching was successful when the parents identify which conditions as factors that predispose the child to a sickle cell crisis? Select all that apply. cold air temperature infection fluid overload pallor respiratory distress
cold air temperature infection Explanation: Factors that may precipitate a sickle cell crisis include, fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.
Question 55 The client has a cast applied for a comminuted fracture of the left radius. The client returns to the emergency department (ED) with reports of pain described as "unrelenting." Which objective findings indicate that the client is experiencing acute compartment syndrome? Select all that apply. deep throbbing pain coolness in the extremity distal to the fracture compartment pressure of 22mm Hg pins and needles sensation poor skin color and delayed capillary refill
coolness in the extremity distal to the fracture compartment pressure of 22mm Hg coolness in the extremity distal to the fracture compartment pressure of 22mm Hg Explanation: Temperature changes, poor skin color, delayed capillary refill, and compartment pressure of 20-30 mm Hg are all objective findings of acute compartment syndrome. Deep throbbing pain and pins and needles sensation are subjective findings.
A client is admitted with inflammatory bowel syndrome (Crohn's disease). When planning care for the healthcare team, which would be included? Select all that apply. antidiarrheal medications high-fiber diet high-protein milkshakes lactulose therapy corticosteroid therapy
corticosteroid therapy antidiarrheal medications Explanation: Inflammatory bowel syndrome (Crohn's disease) is an inflammatory bowel disease caused by inflammation to the lining of the digestive tract which can lead to abdominal pain, severe diarrhea, and even malnutrition. Corticosteroids such as prednisone reduce the signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation. Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis. Lactulose is used to treat chronic constipation and would aggravate the symptoms of Crohn's disease. A high-fiber diet and milk and milk products are contraindicated in clients with Crohn's disease because they may promote diarrhea.
Question 56 A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which signs and symptoms? Select all that apply. Trousseau's sign cardiac arrhythmias constipation decreased clotting time drowsiness and lethargy fractures
fractures Trousseau's sign cardiac arrhythmias Explanation: Chronic renal failure is the slow process of losing kidney function over time. At some point, the kidney will not be able to remove excess fluid and wastes from the body causing fluid and electrolyte complications. Hypocalcemia is a calcium deficit that causes nerve fiber irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include Trousseau's sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and irritability. The calcium-phosphorus imbalance leads to brittle bones and pathologic fractures. Drowsiness and lethargy are not typically associated with hypocalcemia.
An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of: Hashimoto's thyroiditis. thyroid storm. cretinism. myxedema coma.
myxedema coma. Explanation: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. What is the most important instruction to emphasize to the mother to avoid an emergency situation? "Gather all of your supplies before you begin." "Call the doctor immediately if the stoma is not pink/red and moist." "You may need adhesive remover to ease pouch removal." "You must be meticulous in caring for the surrounding skin."
"Call the doctor immediately if the stoma is not pink/red and moist." Explanation: A healthy stoma is pink and moist. If the stoma is dry or pale, the mother must notify the health care provider immediately because it could indicate compromised circulation. Gathering supplies is important but would not be involved in avoiding an emergency situation. All of the other instructions are valid, but emphasizing the color of the healthy stoma is most important to avoid an emergency situation. Adhesive remover may be needed to ease pouch removal, but this action would not necessarily avoid an emergency situation. Meticulous skin care is important, but this action would not necessarily avoid an emergency situation.
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands the condition and how to control it? "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates." "I should be sure to limit my food and fluid intake when I'm not feeling well so my blood sugar doesn't go up." "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."
"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Explanation: Stating the need to remain hydrated and pay attention to eating, drinking, and voiding needs indicates that the client understands HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of non-diet soda would be appropriate for hypoglycemia. Limiting fluids will exacerbate the development of HHNS; limiting food might be acceptable, but it may lead to ketosis. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.
A client who plays football with friends is to take methotrexate orally for severe rheumatoid arthritis. What should the nurse tell the client about taking this drug? Select all that apply. "Increase your fluid intake to 3,000 mL per day." "Limit or avoid use of alcoholic drinks." "Your health care provider will monitor your blood work to determine liver disease and blood count." "You should avoid the chance of becoming bruised." "This drug will slow the progression of joint damage." "Plan to increase the protein in your diet."
"Limit or avoid use of alcoholic drinks." "Your health care provider will monitor your blood work to determine liver disease and blood count." "You should avoid the chance of becoming bruised." "This drug will slow the progression of joint damage." Explanation: Methotrexate is used for clients with rheumatoid arthritis to decrease the progression of the disease and relieve pain. Side effects of the methotrexate include decreased white blood cells and platelets and the potential for liver disease. The nurse should instruct the client to avoid infection and report signs such as fever, child or cough. The client should avoid contact sports that could cause bruising. The client should also limit the amount of alcohol use to avoid liver damage. The client will have frequent blood tests to monitor liver enzymes and complete blood count. It is not necessary for the client to increase the protein in the diet or increase fluid.
