AH 2 Final
The nurse provides care for a client diagnosed with type 2 diabetes mellitus. Which client statement indicates the client understands the diagnosis? a. "I need to follow my diet and take my pills." b. "If I do not take my insulin pills, I will go blind." c. "I should not eat anything that contains glucose." d. "I am ready to learn how to give myself shots."
a. "I need to follow my diet and take my pills." This statement indicates an understanding of diabetes mellitus type 2. A client diagnosed with diabetes mellitus type 2 may not need insulin. Most clients maintain the disease with diet, weight control, and oral hypoglycemic agents with insulin added if blood glucose still cannot be controlled.
The nurse provides instruction about self-monitoring blood glucose to a client diagnosed with type 1 diabetes. Which client statement indicates to the nurse further teaching is required? a. "I will check my blood glucose once a day in the morning and if I feel like my blood glucose is low." b. "I can buy my monitor at a store where someone can teach me how this brand of monitor works." c. "Every six months, I will compare the readings from my monitor with those obtained when my blood glucose is tested in the lab." d. "I will call my health care provider if my blood glucose falls outside the range of values I have been given."
a. "I will check my blood glucose once a day in the morning and if I feel like my blood glucose is low." Most people diagnosed with type 1 diabetes need to check blood glucose levels at least two to four times a day. Those clients who take insulin before meals will need to check at least three times a day. A client should be instructed to obtain a blood glucose reading if experiencing any symptoms of hypoglycemia.
The nurse instructs a client diagnosed with urolithiasis how to prevent calcium calculi. Which statement indicates teaching is successful? a. "I will drink at least 3,000 mL of fluid each day." b. "I will eat 2 servings of meat or cheese per day." c. I will drink at least two glasses of cranberry juice daily." d. "I will eat a large amount of citrus fruit each day."
a. "I will drink at least 3,000 mL of fluid each day." The client will drink 3,000 mL of fluid each day to produce dilute urine and decrease their risk of developing calculi.
A client is newly diagnosed with type 1 diabetes. The nurse talks with the client prior to discharge and discovers that the client lives alone. Discharge planning should include arranging home visits by which health care provider? a. A home health nurse b. A physical therapist c. An occupational therapist d. A respiratory therapist
a. A home health nurse The home health nurse can assess this client's educational needs, self-care needs, and medication administration needs after discharge and request appropriate services to support the client.
The nurse understands that which client is most at risk to develop urinary tract calculi? a. Client who is a vegetarian. b. Client who consumes a low sodium diet. c. Client with polycystic kidney disease. d. Client with diabetic nephropathy.
a. Client who is a vegetarian. Consumption of foods high in calcium or oxalate rich foods (soy, tofu, spinach) increase urine alkalinity and the risk of calculi formation.
The nurse provides care for a client diagnosed with a peptic ulcer. Which nursing action is most appropriate? a. Identify stress factors in the client's environment. b. Avoid giving the client choices to make. c. Encourage the client to become angry. d. Avoid discussing the client's symptoms.
a. Identify stress factors in the client's environment. It is important to identify elements in the client's environment that are contributing to stress when caring for a client with a psychophysiological disorder. Work habits and personal habits, such as smoking and drinking, must be evaluated to encourage the client adopt a less stressful lifestyle.
The client's arterial blood gases (ABG) are pH 7.49 PaCO2 37 mm Hg PaO2 96 mm Hg SaO2 98% HCO3 24 mEq/L Potassium 4.2 mEq/L The nurse understands the blood gases suggest the client is experiencing which condition? a. Respiratory alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Metabolic alkalosis
a. Respiratory alkalosis pH 7.35-7.45; pH is high CO2 35-45; CO2 is within range CO3 24-28; CO3 is low/within range
The nurse provides care for a client admitted with a diagnosis of acute pancreatitis. The nurse administers morphine sulfate intravenously for reports of pain. Which client behavior indicates to the nurse the medication is effective? a. The client sleeps for one hour. b. The client frequently changes position in bed. c. The client states there is less nausea. d. The client does not report thirst.
a. The client sleeps for one hour. Acute pancreatitis causes severe abdominal pain. Pain increases body metabolism, which increases secretion of pancreatic and gastric enzymes. The client sleeping and relaxed indicates the morphine is effective. The nurse will evaluate the client's pain on a scale before and after administering the medicaiton.
A client is diagnosed with type 2 diabetes mellitus. The nurse provides information about the client's total caloric and carbohydrate plan and the use of food exchange lists. Which client statement indicates the client understands the teaching? a. "I wont be able to eat things like pizza and spaghetti." b. "I can have a turkey and cheese sandwich for lunch if I substitute one ounce of cheese for one ounce of turkey." c. "It is better to drink fruit juice instead of eating a lot of fruit." d. "The main goal for the change in my diet and using the exchange list is for me to lose weight."
b. "I can have a turkey and cheese sandwich for lunch if I substitute one ounce of cheese for one ounce of turkey." This answer shows an appropriate understanding about how to use the exchange system for meal planning. Foods on the same list can be exchanged for each other, to give variety and choice to an otherwise structured plan.
The nurse in the outpatient clinic counsels the client with a diagnosis of cholecystitis. The nurse determines teaching is successful if the client makes which statement? a. "I really like a lot of cream in my oatmeal." b. "We eat a lot of broiled fish and chicken." c. "I can't wait to eat the chocolates my children gave me." d. "My favorite dish is broccoli with cheese sauce."
b. "We eat a lot of broiled fish and chicken." Broiled lean meats are high in protein and low in fat. The client should avoid meats that are fried or have high fat content. Cooked fruits, non-gas forming vegetables, bread, and cereals are also allowed.
The nurse provides care for a diagnosed with cholelithiasis. It is most important for the nurse to instruct the client to avoid which foods? (Select all that apply.) a. Apples b. Broccoli c. Lettice d. Cheese e. Bacon f. Carrots
b. Broccoli d. Cheese e. Bacon The client should be instructed to avoid vegetables which can cause gas formation and lead to a painful flareup of symptoms. Cheese is high in cholesterol and fat. Cream, butter, whole milk, and ice cream should be avoided. The client should avoid fried foods and foods with high amounts of fats or calories. Bacon and other meats high in fat and cholesterol should be avoided. Amounts of fish and meat containing high amounts of oil and fat should be reduced. Egg yolks and avocado should also be avoided.
The nurse understands which is the principal reason for the use of enzyme inhibitors (acetazolamide) in a client with pancreatitis? a. Pancreatic enzymes are irritating to the liver. b. Pancreatic enzymes escape into interstitial tissue. c. Pancreatic enzymes are missing and must be replaced. d. Pancreatic enzymes are inactivated and must be enhanced.
b. Pancreatic enzymes escape into interstitial tissue. Interstitial pancreatitis is characterized by a swelling of the pancreas and the escape of its digestive enzymes, lipase and amylase, into the surrounding pancreatic tissue. Acetazolamide is a carbonic anhydrase inhibitor. It helps inactivate the enzymes to help minimize the damage they cause to normal tissue. IT can also decrease the overall production of the enzymes to decrease the volume of pancreatic secretion.
The nurse finds a neighbor unresponsive in the front yard. The neighbor's spouse tells the the nurse that a short time ago the spouse was confused and sweaty. The nurse discovers the spouse was recently diagnosed with type 1 diabetes. Which action is best for the nurse to take? a. Ask the spouse to drink sweetened orange juice. b. Place some sugar under the spouse's tongue. c. Offer the spouse sweetened coffee. d. Instruct the spouse to take the next dose of insulin.
b. Place some sugar under the spouse's tongue. The client should not be given anything to swallow because the client may aspirate due to being unconscious. Sugar under the tongue may be absorbed and raise the glucose level enough so the client can drink. Hypoglycemia (abnormally low blood glucose level) may occur at any time, but often occurs at the time the insulin is peaking. Symptoms of hypoglycemia include tremor, perspiration, anxiety, hunger, weakness, tachycardia, confusion, and headache.
The nurse provides care for a client reporting a sudden onset of severe right flank pain. The client is diagnosed with urinary calculi. Which nursing action has the immediate priority? a. Ensuring the client remains NPO. b. Reliving pain. c. Straining the urine. d. Obtaining a mid-stream urine specimen.
b. Reliving pain. Severe acute pain is often the presenting symptom of a client with kidney and/or urinary calculi and requires immediate attention. Reliving the client's pain is the immediate priority.
On the day of discharge, a client newly diagnosed with type 1 diabetes says to the nurse, "What should I do if I develop a fever?" Which response by the nurse is best? a. "Increase your caloric intake and decrease your insulin dosage." b. "Discontinue taking insulin until after your febrile state has passed." c. "Continue taking insulin as prescribed." d. "Go to the emergency department if your fever lasts more than 12 hours."
c. "Continue taking insulin as prescribed." Some of the hormones involved in mounting a defense to illness or infection also raise blood sugar. Insulin should be continued as prescribed and the health care provider should be contacted for any adjustments that may need to be made based on blood glucose levels.
The nurse assesses a client in the outpatient clinic with a diagnosis of ulcerative colitis. While obtaining the client's history, the nurse expects the client to make which statement? a. "I feel a constant sharp pain in my lower abdomen." b. "I feel an intermittent gnawing pain in my middle abdomen." c. "I feel an intermittent cramping pain in my lower abdomen." d. "I feel a burning pain in my upper esophagus after I eat."
c. "I feel an intermittent cramping pain in my lower abdomen." The pain associated with ulcerative colitis is usually described as cramping and intermittent and is located in the lower abdomen. It occurs prior to defecation. It is important that the nurse assess location, character, and intensity of pain. The nurse should obtain a diet history and assess for bowel sounds and for areas of tenderness.
The nurse provides care for a client newly diagnosed with type 1 diabetes mellitus. The nurse instructs the client about the diabetic regimen. Which statement indicates the client requires further instruction? a. "I will always have to take insulin by injection." b. "I will program my glucometer every time I open a new bottle of test strips." c. "I will increase my insulin dose on holidays so I can eat more." d. "I will substitute brown rice for whole wheat bread because I dislike bread."
c. "I will increase my insulin dose on holidays so I can eat more." The client should never adjust insulin dosages without consulting the health care provider. The client may be able to adjust insulin dosage to account for carbohydrate load under the supervision and guidance of the health care provider.
An adolescent client is diagnosed with type 1 diabetes mellitus. Which statement best indicates the client understands the effects of strenuous exercise on blood glucose levels. a. "I should eat more calories all the time, since I play sports." b. "Since exercise burns up calories, I won't need my insulin on the days I swim." c. "I will need to eat a snack before I go to swim team practice." d. "I can go out for ice-cream after the game with the rest of the team."
c. "I will need to eat a snack before I go to swim team practice." Exercise will lower the blood glucose level because insulin is utilized more effectively and there is increased uptake of glucose by muscles. Having a snack before exercising to keep blood glucose in a safe range.
A client is prescribed rifampin and isoniazid. Which explanation concerning these medications is most appropriate for the nurse to give the client? a. "You will have to take these medications for the rest of your life." b. "You must isolate yourself from your family while on these medications." c. "You will have to take these medications for 6 to 9 months." d. "You will need to take these medications only when you have symptoms."
c. "You will have to take these medications for 6 to 9 months." It is very important that people who have TB disease are treated, take the medication exactly as prescribed, and complete the medication regimen. Due to the development of drug-resistant strains of TB, multiple medications are prescribed. If a client stops taking the medications too soon, the client can become sick again. If a client does not take the medications correctly, the TB bacteria that are still alive may become more resistant to those medications. TB that is resistant to drugs is harder and more expensive to treat.
The home health care nurse visits a client with a diagnosis of ulcerative colitis. The client reports perennial irritation due to frequent stools. Which suggestion by the nurse is best? a. Apply a heat lamp to the perineal area three times a day. b. Use protective plastic bed pads. c. Clean the perineal area with soap and water after each bowel movement. d. Increase roughage in the diet to prevent the frequent stools.
c. Clean the perineal area with soap and water after each bowel movement. Cleaning the area keeps the skin free of stool and decreases irritations. The nurse can suggest the use of sitz baths. The client may apply petroleum jelly to the area to soothe irritated skin.
A client reports increased thirst, frequent urination, and hunger. The client is diagnosed with type 1 diabetes. Which symptom reported by the client causes the nurse the most concern when planning care for the client? a. Fatigue b. Difficulty sleeping c. Constant thirst d. Perennial itching
c. Constant thirst The client has frequent urination related to hyperglycemia, which causes dehydration. This is also why the client has polydipsia (increased thirst). Dehydration can become profound in untreated type 1 diabetes. The client is at high risk for hypovolemia and vascular collapse.
The nurse provides care for a client who expresses apprehension about the diagnosis of terminal lung cancer. The nurse notes the clients blood pressure us 140/88, pulse 92 beats per minute, and respirations of 36 per minute. The client's blood gasses are pH 7.52 PaO2 95 mm Hg PaCO2 30 mm Hg HCO3 24 mEq/L Which action does the nurse take first? a. Administer oxygen at two liters. b. Prepare the client for a tracheostomy. c. Encourage the client to breathe into a paper bag. d. Administers bicarbonate intravenously.
c. Encourage the client to breathe into a paper bag. The client's vital signs and blood gases suggest respiratory alkalosis. A respiratory rate of 36 indicates hyperventilation, probably secondary to apprehension and fear. The nurse should implement action that will safely raise the client's PaCO2 level. The nurse would encourage the client to take slow, deep breaths and breathe in and out of a paper bag. This action will allow the client to rebreathe CO2.
The nurse cares for the client with Crohn's disease. Which finding describes a common complication of Crohn's disease? a. Reflux esophagitis b. Chronic constipation c. Fistulas d. Hypothermia
c. Fistulas fistulas, abnormal tracts between two or more body areas, may involve the gastrointestinal tract and the skin, bladder, or vagina
A client is diagnosed with type 2 diabetes mellitus. Which factor contributes to the insulin resistance seen in type 2 diabetes? a. Autoimmune destruction of beta cells in the pancreas b. History of mumps infection as a child c. Increased waist circumference size d. Increased glucagon secretion from alpha cells in the pancreas
c. Increased waist circumference size Increased waist size ("apple shape") is an indicator of an increased risk of type 2 diabetes. Weight reduction and decreased waist circumference decreases insulin resistance and lowers blood glucose.
The nurse instructs the client recently diagnosed with type 1 diabetes about proper meal planning. Which action should the nurse take first? a. Instruct the client about the importance of eating regular meals. b. Inform the client that 50-60% of calories should come from carbohydrates. c. Obtain a diet history that includes the client's favorite foods and usual meal patterns. d. Teach the client how to use the Exchange List for Meal Planning.
c. Obtain a diet history that includes the client's favorite foods and usual meal patterns. Assessment; prior to beginning teaching, the nurse should obtain a through diet history as well as obtain the client's weight and determine whether there is a need for weight loss, weight gain, or weight maintenance; goal of diet is for client to maintain a reasonable weight and control blood glucose; client more likely to make the lifestyle changes required
The nurse provides care for an older adult client. The client is diagnosed with a pathological fracture of the 9th thoracic vertebra. What is the most likely cause of the fracture for this client? a. Osteogenesis imperfecta b. Osteogenic sarcoma c. Osteoporosis d. Osteochondroma
c. Osteoporosis Primary osteoporosis is more common in postmenopausal women. A loss of bone mass occurs due to the loss of estrogen. Compression fractures of the spine are common due to loss of vertebral bone mass.
Which disease is a 70-year-old African American client at highest risk of developing? a. Osteoporosis b. Hyperthyroidism c. Type 2 diabetes mellitus d. Skin cancer
c. Type 2 diabetes mellitus Clients at greatest risk for developing type 2 diabetes have these characteristics: overweight; age 45 or older; have a parent, brother, or sister with type 2 diabetes; physically less active than 3 times a week; had gestational diabetes (diabetes while pregnant) or gave birth to a baby weighing more than 9 pounds; are African American, Hispanic/Latino American, American Indian/Alaska Native, Pacific Islander, or Asian American.
A client is diagnosed with type 1 diabetes and receives 25 units of regular insulin subcutaneously every morning. The nurse discusses the treatment plan with the client. Which statement provides correct information to the client? a. "Keep the insulin refrigerated after it is opened." b. "Vision problems will improve after you take insulin for a few weeks." c. "Carefully round the corners when you cut your toenails." d. "Continue to take insulin if you become ill with a virus."
d. "Continue to take insulin if you become ill with a virus." The client should always take the prescribed dose of insulin. illness can cause glycogen to be released from the liver, and it cannot be metabolized unless insulin is present. The client can get diabetic ketoacidosis (DKA) if the insulin is not taken appropriately.
The nurse counsels a client diagnosed with type 2 diabetes. The client states, "I don't think I can follow this diet!" Which response by the nurse is most appropriate? a. "You have to follow the diet that your health care provider prescribed." b. "What makes you cheat on this diet?" c. "If you don't follow the diet, you might go blind." d. "Tell me what you find frustrating about the diet."
d. "Tell me what you find frustrating about the diet." it is important to reflect the feelings that the client is expressing; nurse should assess the reason that client is having difficulty
The nurse provides care for a client diagnosed with active tuberculosis. Which instructions does the nurse give to the client about follow-up care after discharge from the hospital? a. "We would like you to come back to the clinic monthly to recheck your tine test and look for changes in your chest x-ray." b. "We would like you to return to the clinic only if you experience any adverse side effects from the medications." c. "We would like you to come to the clinic weekly for your isoniazid injections." d. "We would like you to come to the clinic monthly to check the effects of the medication you are taking."
d. "We would like you to come to the clinic monthly to check the effects of the medication you are taking." Having the client actually come to the clinic monthly will allow the nurse to assess the client's physical health, nutritional status, and medication compliance, and to discuss any questions or concerns the client may have. Additionally, liver function tests, chest x-rays, and sputum samples will need to be monitored until the treatment plan is complete.
The nurse teaches a client diagnosed with tuberculosis. The nurse explains which is the cause for tuberculosis? a. A virus b. Poor sanitation c. Poor nutrition d. A bacterium
d. A bacterium Tuberculosis is caused by the bacterium Mycobacterium tuberculosis which is transmitted via the aerosol route (coughing, laughing, sneezing, or singing).
In which age group is diabetes mellitus type 2 most likely to occur? a. Children b. Adolescents c. Older adults d. Adults
d. Adults Diabetes mellitus type 2 is usually a disease of middle age, and is currently experiencing a tremendous epidemic in the United States. Researches believe the cause is directly related to the consumption of refined sugars and carbohydrates. There here is also an increase in young adults being diagnosed with type 2 diabetes mellites.
The nurse provides care for a client diagnosed with poorly controlled type 1 diabetes mellitus. Which finding is the earliest manifestation of diabetic nephropathy? a. Increased urinary output b. Periorbital edema c. Increased serum potassium d. Albumin in the urine
d. Albumin in the urine The earliest sign of diabetic nephropathy is microalbuminuria, which is protein or albumin in the urine. Clients with poorly controlled diabetes mellitus, hypertension, a 10 to 15 year history of diabetes, or the presence of diabetic retinopathy are at increased risk.
The client reports sleepiness, nausea, and vomiting. The nurse notes the client is confused and and respirations are deep and labored with a respiratory rate of 32 breaths per minute. The arterial blood gas values are PaCO2 30 mm Hg pH 7.30 HCO3 20 mEq/L Which action does the nurse take? a. Start an infusion of 5% dextrose and water as per standing orders and contacts the health care provider. b. Place a paper bag over the client's nose and mouth to re-breathe expired air. c. Give morphine intravenously to relive the client's pain. d. Place the client in Fowler's position and encourages measures to support hyperventilation.
d. Place the client in Fowler's position and encourages measures to support hyperventilation. Fowler's position will allow full chest expansion and hyperventilation in the respiratory compensatory mechanism for the client's metabolic acidosis.
A client diagnosed with type 1 diabetes mellitus contacts the nurse to report experiencing night sweats, headaches when arising in the morning, and slight weight gain. The client's urine tests are negative for glucose and positive for ketones. The client's fasting blood glucose is 300 mg/dL (16.65 mmol/L). The nurse identifies the client may be experiencing which condition? a. Diabetic ketoacidosis (DKA) b. Hyperglycemic hypermolar nonketotic coma c. Graves disease d. Somogyi phenomenon
d. Somogyi phenomenon The symptoms described indicate the client is hypoglycemic during the night, but due to hormonal response to low glucose, is hyperglycemic upon arising. This is known as Somogyi phenomenon. The client may have taken too much insulin or skipped a bedtime snack, resulting in a sharp decrease in blood sugar. Hormones like cortisol, glucagon, and epinephrine work to raise the blood glucose level in response to hypoglycemia.
The nurse cares for a client with a diagnosis of ulcerative colitis. When reviewing the client's record, the nurse expects to find which lab value? a. Red blood cell count (RBC) 4 million/mm3 b. Platelet count 75,000/mm3 c. Hemoglobin (Hgb) 18.2 g/dL d. White blood cell count (WBC) 15000/mm3
d. White blood cell count (WBC) 15,000/mm3 Due to inflammation, WBCs and erythrocyte sedimentation rate will be elevated. Normal WBC for adults is 4,500 - 11,000/mm3. Sodium, potassium, and chloride levels may be decreased due to frequent diarrhea.
