Exam 3

Which information will the nurse include in teaching a patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? Choose flat-soled leather shoes. Set heating pads on a low temperature. Use callus remover for corns or calluses. Soak feet in warm water for an hour each day.

Choose flat-soled leather shoes.

Which finding by the nurse will be most helpful in determining whether a 67-year-old client with benign prostatic hyperplasia (BPH) has an upper urinary tract infection (UTI)? Bladder distention Foul-smelling urine Suprapubic discomfort Costovertebral tenderness

Costovertebral tenderness

A 30 year-old patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patient's care? Decisional conflict related to treatment options Disturbed body image related to changes in physical appearance Spiritual distress related to changes in cognitive function Powerlessness related to disease progression

Disturbed body image related to changes in physical appearance

Which is a clinical manifestation of diabetes insipidus? Excessive activities Excessive thirst Weight gain Low urine output

Excessive thirst

Two weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider? Hemoglobin A1C level is 7.9%. Last eye exam was 18 months ago. Glomerular filtration rate is decreased. Patient has questions about the prescribed diet.

Glomerular filtration rate is decreased.

Which statement about a newly diagnosed type 1 diabetes client is correct? Insulin is used to control blood glucose in patients with type 1 diabetes. Complications of type 1 diabetes are less serious than those of type 2 diabetes. Changes in diet and exercise may control blood glucose levels in type 1 diabetes. Type 1 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

Insulin is used to control blood glucose in patients with type 1 diabetes.

A patient with a history of heart failure who is undergoing peritoneal dialysis has developed crackles in the lower lung fields. The nurse interprets this finding is most likely related to: Natural progression of renal failure Compliance with dietary sodium restriction Intake greater than output on the dialysis record Adherence to digoxin therapy schedule

Intake greater than output on the dialysis record

Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetes clinic? Measure the ankle-brachial index. Check for changes in skin pigmentation. Assess for unilateral or bilateral foot drop. Ask the patient about symptoms of depression.

Measure the ankle-brachial index.

During care of a patient with SIADH, what should the nurse do? Medicate with Desmopressin Monitor neurologic status frequently Treat with Beta Blockers Encourage fluids

Monitor neurologic status frequently

A client receiving thyroid replacement therapy develops influenza and forgets to take thyroid replacement medicine for a few days. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication? Diabetes insipidus Thyroid storm Exophthalmos Myxedema coma

Myxedema coma

A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do? Evaluate the quality of the client's voice postoperatively, noting any drastic changes. Observe for swelling of the neck, tracheal deviation, and severe pain. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Monitor laboratory values daily for elevated thyroid-stimulating hormone.

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Which interventions are appropriate for a patient with diabetes and poor wound healing? Select all that apply. Perform dressing changes twice a day as ordered Teach the patient about signs and symptoms of infection Instruct the family about how to perform dressing changes Gently refocus patient from discussing body image changes Administer medications to control the patient's blood sugar as ordered

Perform dressing changes twice a day as ordered Teach the patient about signs and symptoms of infection Instruct the family about how to perform dressing changes Administer medications to control the patient's blood sugar as ordered

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? Place the patient on a cardiac monitor. Administer IV potassium supplements. Obtain urine glucose and ketone levels. Start an insulin infusion at 0.1 units/kg/hr.

Place the patient on a cardiac monitor.

A patient with acute renal failure is ordered to be on a fluid restriction of 1500 mL per day. The nurse best plans to assist the patient with maintaining the restriction by: Removing the water pitcher from the bedside Using mouthwash with alcohol for mouth care Prohibiting beverages with sugar to minimize thirst Asking the client to calculate the IV fluids into the total daily allotment

Removing the water pitcher from the bedside

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? Encouraging increased oral intake Administering glucose-containing I.V. fluids as ordered Restricting fluids Infusing IV fluids rapidly as ordered

Restricting fluids

A client with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the client's plan of care? Impaired physical mobility related to presence of an indwelling urinary catheter Risk for infection related to presence of an indwelling urinary catheter Toileting self-care deficit related to urinary catheterization Disturbed body image related to urinary catheterization

Risk for infection related to presence of an indwelling urinary catheter

A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's post procedure care? Strain the client's urine following the procedure. Administer a bolus of 500 mL normal saline following the procedure. Monitor the client for fluid overload following the procedure. Insert a urinary catheter for 24 to 48 hours after the procedure.

Strain the client's urine following the procedure.

The nurse is assessing a patient after a thryoidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? Tetany Thyroid storm Hemorrhage Laryngeal nerve damage

Tetany

The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the physician that the client may be exhibiting signs of acute kidney injury (AKI)? The client's average urine output has been 10 mL/hr for several hours. The client reports an inability to initiate voiding. The client's urine is cloudy with a foul odor. The client reports abdominal/flank pain.

The client's average urine output has been 10 mL/hr for several hours.

A patient visits the physician's office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves' disease. Based on history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by: a wide, staggering gait. more than 10 beats/minute difference between the apical and radial pulse rates. dry, waxy swelling and abnormal mucin deposits in the skin. protruding eyes and a fixed stare.

protruding eyes and a fixed stare.

The nurse is caring for a client who has a fluid volume deficit. When evaluating this client's urinalysis results, what should the nurse anticipate? A fluctuating urine specific gravity A fixed urine specific gravity A decreased urine specific gravity An increased urine specific gravity

An increased urine specific gravity

The nurse is preparing to teach a 43-year-old client who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? Ask the patient's family to participate in the diabetes education program. Assess the patient's perception of what it means to have diabetes mellitus. Demonstrate how to check glucose using capillary blood glucose monitoring. Discuss the need for the patient to actively participate in diabetes management.

Assess the patient's perception of what it means to have diabetes mellitus.

The nurse is preparing to teach a patient who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? Ask the patient's family to participate in the diabetes education program. Assess the patient's perception of what it means to have diabetes mellitus. Demonstrate how to check glucose using capillary blood glucose monitoring. Discuss the need for the patient to actively participate in diabetes management.

Assess the patient's perception of what it means to have diabetes mellitus.

Nursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for HAI in clients admitted to the hospital? Encouraging adequate oral fluid intake Testing urine with a dipstick daily for nitrites Avoiding unnecessary urinary catheterizations Providing frequent perineal hygiene to patients

Avoiding unnecessary urinary catheterizations

Which assessment data reported by a 28-year-old client (assigned female at birth) is consistent with a lower urinary tract infection (UTI)? Poor urine output Bilateral flank pain Nausea and vomiting Burning on urination

Burning on urination

The patient with chronic renal failure who is scheduled for hemodialysis this morning is scheduled to receive a daily dose of enalapril. The nurse plans to administer this medication: During dialysis Just before dialysis The day after dialysis Upon return from dialysis

Upon return from dialysis

Which of the following are manifestations of Addison's disease? Select All That Apply Weight loss and decreased appetite Hypoglycemia GI disturbances Hyperglycemia Weight gain and extreme hunger

Weight loss and decreased appetite Hypoglycemia GI disturbances

A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? thigh. buttock. abdomen. upper arm.

abdomen.

The nurse is developing a teaching plan for a patient diagnosed with diabetes insipidus. The nurse should include information about which hormone that is lacking in patients with diabetes insipidus? luteinizing hormone (LH) thyroid-stimulating hormone (TSH) antidiuretic hormone (ADH) follicle-stimulating hormone (FSH)

antidiuretic hormone (ADH)