Unit 2
When teaching a client with type 2 diabetes, which statement by the nurse reflects accurate information about preparing for a serum glucose test?
"Do not ingest anything before the test"
The nurse working at a women's health clinic is seeing a teenage female patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain. When the nurse enter the room, the patient is sitting in the chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be addressed once safety is addressed?
"Do you feel safe in your current relationship?"
The nurse is seeing a patient who has been in the clinic eight times in the past 6 months for injuries from an abusive partner. The patient states, "I don't see any way to get away from my partner, and I can't keep going on like this." What assessment question is most important for the nurse to ask?
"Have you thought about hurting yourself or someone else?"
Which statement by the nurse reflects understanding of therapeutic communication with a client experiencing domestic violence?
"Tell me about your struggles"
When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? A) "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP." B) "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis." C) "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." D) "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity."
"The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel."
The nurse teaches the parent of a 5-year old boy with type 1 diabetes about blood glucose monitoring at home. Which statement by the parents indicates that the teaching has been effective?
"We'll notify the clinic if the blood sugar is higher than 200"
Which statement is accurate when teaching the client with diabetes about foot care?
"Wear synthetic fiber socks when exercising"
What is the nurse's best response about developing diabetes to the patient whose father has type 1 diabetes?
"You have a greater susceptibility for development of the disease because of your family history."
A nurse is caring for a patient in the ED who has been a victim of intimate partner violence. What is the most important for the nurse to include in the plan of care?
A list of community resources
Which hormonal deficiency causes diabetes insipidus in a client?
ADH
Following a parathyroidectomy, which electrolyte should the nurse most closely monitor?
Calcium
Radioactive iodine is indicated for the treatment of hyperthyroidism. Which item should the nurse include in the plan of care?
Continued thyroid monitoring is required
The public health nurse is developing a program geared toward primary prevention of domestic violence. Which information would the nurse include in the program for those at high risk?
Coping skills, social support, stress reduction
After shunt procedure, the nurse would monitor the patient's neurologic status by using what test?
Glasgow coma scale
A student with type 1 diabetes asks the nurse which hormone causes the blood glucose level to rise. Which hormone would the nurse report?
Glucagon
The nurse is caring a patient who has undergone a thyroidectomy. Which patient complain is highest priority requiring further evaluation?
Horaseness
A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestations is seen in uncontrolled diabetes mellitus and ketoacidosis?
Increased respiratory rate
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information would the nurse give to this client?
Insulin needs will increase during the second trimester
Which metabolic manifestations are likely to be observed in a client with hypothyroidism?
Intolerance to cold, decreased body temperature
A lactating mother is administered oxytocin. The nurse understands which to be the function of oxytocin in this client?
It helps with the ejection of milk
The nurse recognizes which patient as having the greatest risk for undiagnosed DM?
Middle-aged native american woman
The nurse is caring for a patient diagnosed with syndrome of inappropriate hormone (SIADH). What is the nurse's best action?
Monitor for changes in level of conciousness
Which statement most accurately describes women who are involved in a situation of domestic violence?
Most women try to leave about 6 times before they are successful
Which clinical manifestation results in elevate serum ACTH and urine cortisol levels?
Pituitary Cushing syndrome
The nurse associates which assessment finding in the diabetic patient with decreasing renal function?
Protein in the urine during a random urinalysis
The nurse is admitting a child with history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment?
Reliving abuse incidents, sleep disturbance, acting out behaviors
Which outcome best indicates that the client with type 1 diabetes is successfully managing the disease?
Stabilization of serum glucose
A patient presents to the ER complaining of vomiting with severe back and leg pain. The patient's home medications include daily oral corticosteroids. Vital signs reveal a low blood pressure and there are peaked T waves on the electrocardiogram. What is the nurse's priority intervention?
Start an intravenous line
Which MOA explains how glyburide decreases serum glucose levels?
Stimulates pancreas to produce insulin
Which information regarding hormonal influences would the nurse fully understand when teaching a client about breastfeeding?
Suckling stimulates the pituitary to release oxytocin, which initiates the let-down reflex
A crisis intervention nurse is training ED staff on treatment needs of persons in abusive relationships. What is common difficulty staff encounter when caring for this population?
The abused person may return to the abusive relationships
The nurse caring for a pregnant client at 28 weeks gestation suspects intimate partner violence. Which assessments support this suspicion?
The client has injuries to the breasts and abdomen, the partner answers questions that are asked of the woman, the client has visited the clinic several times in the past month.
Which is an appropriate teaching goal for a client who is newly diagnosed as type type 2 DM?
To identify the symptoms of hypoglycemia or hyperglycemia
Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction?
Tremors, Nervousness, Profuse perspiration, dilated pupils
Which components of the glasgow coma scale should the nurse use to assess a patient after a head injury?
Verbal responsiveness
The nurse is teaching a patient about head injuries. Which information should the nurse include as a primary prevention strategy to reduce the occurrence of head injuries?
Violence prevention
Which statement made by a student nurse indicates the need for additional teaching about pituitary insufficency? "Testosterone supplements may be prescribed for women with gonadotropin" "Synthetic human growth hormone may be prescribed for children who are small for gestational age" "Estrogen is known to regulate the action of GH in men and women" "Chronic kidney disease treatment may include synthetic growth hormone replacement"
"Testosterone supplements may be prescribed for women with gonadotropin"
The nurse is reviewing case files for children at risk for injury resulting in brain injury. Which child is most at risk for experiencing this type of violence?
A Caucasian, 6-month old infant living with a single mother
A client with type 1 diabetes has a finger-stick glucose level of 258 mg/dL at bedtime. A prescription for sliding-scalre regular insulin exists. Which would the nurse do?
Administer the insulin as prescribed
The nurse is caring for a patient with increased ICP. Which action would be considered to be a collaborative intervention?
Administering an osmotic diuretic
The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin?
Aldactone (Spironolactone)
Which hormonal imbalance would the nurse suspect in a client who has low serum sodium levels?
Aldosterone
The nurse preparing to care for a patient after a suspected stroke would question which order?
Antihypertensive
The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive relationships?
Becoming pregnant
Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation?
Changes in level of consciousness
A client experiences ineffective control of type 1 DM, the client's study results indicate that a sudden decreased in blood glucose level is followed by a rebound hyperglycemia. When this event occurs, which action would the nurse take?
Collaborate with the primary HCP to alter the insulin prescription
When determining the main difference between type 1 and type 2 diabetes, the nurse recognizes which clinical presentation about type 1?
Complications are not present at the time of diagnosis
The physical exam of a client reveals moon face, buffalo hump, and truncal obesity. The lab reports revels of salivary cortisol level of 3.9 Hg/mL. Which other manifestations would be present in the client?
Edema, Osteoporosis, and muscle atrophy
When caring for a client after a head injury, the nurse would be most concerned with assessment findings which include respiratory changes along with what other findings?
Hypertension and bradycardia
Which eye problem is the leading cause of blindness in clients with diabetes?
Retinopathy
The nurse determines that an adolescent with newly diagnosed type 1 diabetes has sufficient knowledge of the disorder. Which action is the next appropriate action?
Setting goals with the client.
Which important teaching point should the nurse include in the plan of care for a patient diagnosed with Cushing's disease?
Wash hands frequently
