Nurs 148 test 4
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
The lower abdomen is the best location because it is closest to the pancreas.
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity?
Tonic-clonic Seizure
A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.)
Urine osmolality is decreased Specific gravity is decreased Urine output is increased
A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The client's symptoms have now resolved and the client asks, "When can I stop taking these medications?" How should the nurse respond?
"You must decrease the dose slowly so your hormones will work again."
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching?
"Avoid crowds and people with colds."
A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." How should the nurse respond?
"Hormone abnormalities can cause you to feel this way."
After teaching a client with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
"I hope I can go back to wearing size 8 shoes instead of size 12."
A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this client's teaching?
"Lie down in a darkened room when you experience a headache."
A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond?
"What would you like to be done if you begin to have difficulty breathing?"
A nurse cares for a male client with hypopituitarism who is prescribed testosterone hormone replacement therapy. The client asks, "How long will I need to take this medication?" How should the nurse respond?
"When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever."
A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L. Which action on the list of orders should the nurse take first?
Restrict the client's fluid intake to 600 mL/day.
A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone?
A 42-year-old male who experienced head trauma 3 years ago
A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How should the nurse respond?
A single dose of insulin each day would not match your blood insulin levels to your food intake patterns
A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first?
Administer 1 mg of intramuscular glucagon
At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS)Dietary Intake At 0630: 95 At 1130: 70 At 1630: 47Breakfast: 10% eaten - client states she is not hungry Lunch: 5% eaten - client is nauseous; vomits once After reviewing the client's assessment data, which action is appropriate at this time?
Administer dextrose 50% intravenously and reassess the client
After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional instruction?
After surgery, I won't need to take thyroid medication
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care?
Allow the client to be as independent as possible with activities."
A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client's teaching to decrease the client's insulin needs?
Animal organ meat is high in insulin
A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, "I feel numbness and tingling around my mouth." What action should the nurse take?
Assess for Chvostek's signs
A nurse cares for a client with chronic hypercortisolism. Which action should the nurse take?
Assess the client's daily chest x-ray.
A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching?
Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).
A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism?
I am always tired, even with 12 hours of sleep
A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." How should the nurse respond?
I see you are still hungry. I will get you some toast.
After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
I should decrease my intake of protein and eliminate carbohydrates from my diet
After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?
I should look into swimming or water aerobics to get my exercise.
After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy?
I will take this medicine immediately before I eat
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
Contact the provider and prepare for intubation
A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client?
Depression and withdrawal
After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations?
Diabetes can cause blindness, so I should see the ophthalmologist yearly.
A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections?
Do not share your monitoring equipment
A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take?
Document the finding in the client's chart
A nurse prepares to administer insulin to a client at 1800. The client's medication administration record contains the following information: • Insulin glargine: 12 units daily at 1800 • Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the client's medication administration record, which action should the nurse take?
Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin
A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
Evaluate the client's reaction to a change of environment
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?
Even when my seizures stop, I will continue to take this drug.
A nurse assesses a client who has a 15-year history of diabetes and notes decreased tac-tile sensation in both feet. Which action should the nurse take first?
Examine the client's feet for signs of injury
A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:
Good control of blood glucose
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates she correctly understands changes associated with this disease?
He may have trouble chewing, so I will offer bite-sized portions
A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective?
Heart rate is 70 beats/min and regular
A nurse cares for a client who is prescribed pioglitazone. After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take?
Review the client's liver function study results.
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
Keep bed rails up at all times Ensure that the client has iv access Have suction equipment at the bedside
A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client?
Levothyroxine sodium
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?
Lorazepam (Ativan)
A nurse teaches a client with Cushing's disease. Which dietary requirements should the nurse include in this client's teaching? (Select all that apply.)
Low calories Low carbohydrates Low sodium
A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer?
Methylprednisolone
A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching?
Monitor your blood glucose levels at least every 4 hours while sick
A client is in the preoperative holding area waiting for cataract surgery. The client says "Oh, yeah, I forgot to tell you that I take clopidogrel, or Plavix." What action by the nurse is most important?
Notify the surgeon immediately.
A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?
Nystagmus
A nurse cares for a client who has type 1 diabetes mellitus. The client asks, "Is it okay for me to have an occasional glass of wine?" How should the nurse respond?
One glass of wine is okay with a meal and is counted as two fat exchanges
A nurse is teaching a client who has chronic headaches. Which statements about head-ache triggers should the nurse include in this client's plan of care? (Select all that apply.)
Participate in a smoking cessation program Incorporate physical exercise into your daily routine Increase your intake of fruits and vegetables.
A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.)
Registered dietitian Health care provider Clinical pharmacist
A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take first?
Report clear or light yellow drainage from the nose.
A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?
Serum calcium 6.9 mg/dL
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately?
Serum potassium level of 2.5 mmol/L
After teaching a client with type 2 diabetes mellitus, the nurse assesses the client's under-standing. Which statement made by the client indicates a need for additional teaching?
Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick
A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.)
Stroke Kidney failure Blindness
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this client's teaching?
Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.
A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first?
Take vital signs, including temperature.
A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms. The client asks for options related to family planning. What is the nurse's best response?
Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider.
When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How should the nurse respond?
Tell me what it is about the injections that are concerning you
A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this client's discharge education?
Test your urine daily for ketones.
