MSS Exam 2 Q's

The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my health-care provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."

1. "I will be sure to notify my health-care provider if I start to run a fever." Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease.

The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose IVP. 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level.

1. Administer 50% dextrose IVP. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.

1. Administer steroid medications. Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland.

The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

1. Assess the client's ability to read small print. Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately.

The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership? 1. Call a meeting and educate the staff on the new delivery system being used. 2. Organize a committee to investigate the various types of delivery systems. 3. Wait until another unit has implemented the new system and see if it works out. 4. Discuss with the nursing staff if a new delivery system should be adopted.

1. Call a meeting and educate the staff on the new delivery system being used. An autocratic style is one in which the person in charge makes the decision without consulting anyone else.

The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? 1. Complaints of extreme fatigue and hair loss. 2. Exophthalmos and complaints of nervousness. 3. Complaints of profuse sweating and flushed skin. 4. Tetany and complaints of stiffness of the hands.

1. Complaints of extreme fatigue and hair loss. A decrease in thyroid hormone causes decreased metabolism, which leads to fatigue and hair loss.

The nurse identifies the client problem "risk for imbalanced body temperature" for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care? 1. Discourage the use of an electric blanket. 2. Assess the client's temperature every two (2) hours. 3. Keep the room temperature cool. 4. Space activities to promote rest.

1. Discourage the use of an electric blanket. External heat sources (heating pads, electric or warming blankets) should be discouraged because they increase the risk of peripheral vasodilation and vascular collapse.

The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.

1. Ensure the client eats the bedtime snack. Humulin N peaks in 6 to 8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia.

80. The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client? 1. Explain it will take up to a month for symptoms of hyperthyroidism to subside. 2. Teach the iodine therapy will have to be tapered slowly over one (1) week. 3. Discuss the client will have to be hospitalized during the radioactive therapy. 4. Inform the client after therapy the client will not have to take any medication.

1. Explain it will take up to a month for symptoms of hyperthyroidism to subside. Radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the client is followed closely for three (3) to four (4) weeks until the euthyroid state is reached.

The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas results.

1. Infuse 0.9% normal saline intravenously. The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially of the heart.

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output. (see Med Surg for Success p. 343 for rationale)

The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply. 1. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days. 2. Discuss ways to cope with the emotional lability. 3. Notify the HCP if taking over-the-counter medication. 4. Carry a medical identification card or bracelet. 5. Teach how to take thyroid medications correctly.

1. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days. 2. Discuss ways to cope with the emotional lability. 3. Notify the HCP if taking over-the-counter medication. 4. Carry a medical identification card or bracelet. (rationale on p. 355 of Med Surg Success bk)

The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide an atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) days.

1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 4. Monitor urine and serum osmolality. 1. Fluids are restricted to 500 to 600 mL per 24 hours. 2. Orientation to person, place, and time should be assessed every two (2) hours or more often. 4. Urine and serum osmolality are monitored to determine fluid volume status.

The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider? 1. Serum sodium of 112 mEq/L and a headache. 2. Serum potassium of 5.0 mEq/L and a heightened awareness. 3. Serum calcium of 10 mg/dL and tented tissue turgor. 4. Serum magnesium of 1.2 mg/dL and large urinary output.

1. Serum sodium of 112 mEq/L and a headache. A serum sodium level of 112 mEq/L is dangerously low, and the client is at risk for seizures. A headache is a symptom of a low sodium level.

Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? 1. Serum sodium. 2. Serum calcium 3. Urine glucose. 4. Urine white blood cells.

1. Serum sodium. The client will have an elevated sodium level as a result of low circulating blood volume. The fluid is being lost through the urine. Diabetes means "to pass through" in Greek, indicating polyuria, a symptom shared with diabetes mellitus. Diabetes insipidus is a totally separate disease process.

The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.

1. Start an IV with an 18-gauge needle and infuse NS rapidly. The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an addisonian crisis. Rapid IV fluid replacement is necessary.

The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL. 1. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress. 2. The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. 5. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range.

The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four (4) times a day. 4. The client will maintain normal kidney function with 30-mL/hr urine output.

1. The client will have a blood glucose level between 90 and 140 mg/dL. The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia," and this blood glucose level is within acceptable ranges for a client who is noncompliant.

The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my health-care provider."

2. "I should take my medication in the morning and leave it refrigerated at home." Medication for DI is usually taken every 8 to 12 hours, depending on the client. The client should keep the medication close at hand.

The nurse at a freestanding health care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.

2. Arrange for someone to give him insulin at a local homeless shelter. Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices

The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement? 1. Assess for dehydration and monitor blood glucose levels. 2. Assess for nausea and vomiting and weigh daily. 3. Monitor potassium levels and encourage fluid intake. 4. Administer vasopressin IV and conduct a fluid deprivation test.

2. Assess for nausea and vomiting and weigh daily. Early signs and symptoms are nausea and vomiting. The client has the syndrome of inappropriate secretion of antidiuretic (against allowing the body to urinate) hormone. In other words, the client is producing a hormone that will not allow the client to urinate.

The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.

2. Hold the biguanide medication for 48 hours prior to test. Biguanide medication must be held for a test with contrast medium because it increases the risk of lactic acidosis, which leads to renal problems.

Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia.

2. Hyperpyrexia and extreme tachycardia. Hyperpyrexia (high fever) and heart rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism.

The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.

2. Notify the dietitian about the client's request. The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian talk to the client to try to adjust the meals so the client will adhere to the diet.

The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells.

2. Plasma levels of ACTH and cortisol. The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorticotropic hormone (ACTH), a hormone used by the body to stimulate the production of cortisol.

Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICU? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

2. Potassium The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia.

The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74 mg/dL. 2. Pulse oximeter reading of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The client is lethargic and sleeps all the time.

2. Pulse oximeter reading of 90%. A pulse oximeter reading of less than 93% is significant. A 90% pulse oximeter reading indicates a PaO2 of approximately 60 on an arterial blood gas test; this is severe hypoxemia and requires immediate intervention.

The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention? 1. The client is alert to name but is unable to tell the nurse the location. 2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. 3. The client's vital signs are T 97.6ºF, P 88, R 20, and BP 130/80. 4. The client has a 3-cm amount of dark-red drainage on the turban dressing.

2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. The output is more than double the intake in a short time. This client could be developing diabetes insipidus, a complication of trauma to the head.

The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.

2. The client has been taking steroid medications for an extended period for another disease process. "Iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis.

Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.

2. The client is alert and oriented to date, time, and place. The client's level of consciousness can be altered because of dehydration and acidosis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment.

An 18-year-old female client, 5′4′′ tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes. 2. Type 2 diabetes. 3. Gestational diabetes. 4. Acanthosis nigricans.

2. Type 2 diabetes. Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. This client weighs 248.6 pounds and is short.

The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes?"

3. "Have you had some type of infection lately?" The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks.

The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? 1. Tell the UAP to fill the pitcher with ice cold water. 2. Instruct the UAP to start measuring the client's I & O. 3. Assess the client for polyuria and polydipsia. 4. Check the client's BUN and creatinine levels.

3. Assess the client for polyuria and polydipsia. The first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabetes insipidus, a complication of the head trauma

The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.

3. Bronze pigmentation, hypotension, and anorexia. Bronze pigmentation of the skin, particularly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease.

The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

3. Dry mucous membranes. Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA.

The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every (2) hours.

3. Explain the signs and symptoms of infection and when to call the health-care provider. Notifying the HCP if signs/symptoms of infection develop is an instruction given to all surgical clients on discharge.

The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously.

3. Go to the client's room and assess the client for hypoglycemia. Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable.

The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the health-care provider and significant other. 2. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions. 3. Notify the health-care provider of the client's wishes and give the client fluids as desired. 4. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the health-care provider.

3. Notify the health-care provider of the client's wishes and give the client fluids as desired. This is an example of autonomy (the client has the right to decide for himself).

Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? 1. Thyroid hormones. 2. Oxygen. 3. Sedatives. 4. Laxatives.

3. Sedatives. Untreated hypothyroidism is characterized by an increased susceptibility to the effects of most hypnotic and sedative agents; therefore, the nurse should question this medication.

The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Explain the need to get the annual flu and pneumonia vaccines.

3. Take the prescribed insulin even when unable to eat because of illness. 3. Illness increases blood glucose levels; therefore, the client must take insulin and consume high-carbohydrate foods such as regular Jell-O, regular popsicles, and orange juice.

The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.

3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. This client has a low blood pressure and tachycardia. This client may be experiencing an addisonian crisis, a potentially life-threatening condition. The most experienced nurse should care for this client.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours. 3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. 4. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.

3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the client could begin to seize.

The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails.

3. The client has a necrotic big toe. A necrotic big toe indicates "dead" tissue. The client does not feel pain, does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increase the risk for developing an infection.

The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test? 1. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours. 2. The client will be administered an injection of antidiuretic hormone, and urine output will be measured for four (4) to six (6) hours. 3. The client will be NPO, and vital signs and weights will be done hourly until the end of the test. 4. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.

3. The client will be NPO, and vital signs and weights will be done hourly until the end of the test. The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight or vital signs occurs, the test is immediately terminated.

The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.

3. The client with DKA who has multifocal premature ventricular contractions. Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse.

The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? 1. The client has a three (3)-pound weight gain. 2. The client has a decreased pulse rate. 3. The client's temperature is WNL. 4. The client denies any diaphoresis.

3. The client's temperature is WNL. The client with hypothyroidism frequently has a subnormal temperature, so a temperature WNL indicates the medication is effective.

The nurse is preparing to administer the following medications. Which medication should the nurse question administering? 1. The thyroid hormone to the client who does not have a T3, T4 level. 2. The regular insulin to the client with a blood glucose level of 210 mg/dL. 3. The loop diuretic to the client with a potassium level of 3.3 mEq/L. 4. The cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL.

3. The loop diuretic to the client with a potassium level of 3.3 mEq/L. This potassium level is below normal, which is 3.5 to 5.5 mEq/L. Therefore, the nurse should question administering this medication because loop diuretics cause potassium loss in the urine.

The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.

3. This result is above recommended levels. This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test reflecting average blood glucose levels over a period of three (3) months; clients with elevated blood glucose levels are at risk for developing long-term complications.

The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.

3. Use therapeutic communication to allow the client to discuss feelings. Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face.

Which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism? 1. "I just don't seem to have any appetite anymore." 2. "I have a bowel movement about every 3 to 4 days." 3. "My skin is really becoming dry and coarse." 4. "I have noticed all my collars are getting tighter."

4. "I have noticed all my collars are getting tighter." The thyroid gland (in the neck) enlarges as a result of the increased need for thyroid hormone production; an enlarged gland is called a goiter.

The nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, "Why don't the people in the United States get goiters as often?" Which statement by the nurse is the best response? 1. "It is because of the screening techniques used in the United States." 2. "It is a genetic predisposition rare in North Americans." 3. "The medications available in the United States decrease goiters." 4. "Iodized salt helps prevent the development of goiters in the United States."

4. "Iodized salt helps prevent the development of goiters in the United States." Almost all of the iodine entering the body is retained in the thyroid gland. A deficiency in iodine will cause the thyroid gland to work hard and enlarge, which is called a goiter. Goiters are commonly seen in geographical regions having an iodine deficiency. Most table salt in the United States has iodine added.

The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.

4. Assess tissue turgor every four (4) hours. The client is excreting large amounts of dilute urine. If the client is unable to drink enough fluids, the client will quickly become dehydrated, so tissue turgor should be assessed frequently.

The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority? 1. Altered body image. 2. Activity intolerance. 3. Impaired coping. 4. Fluid volume deficit.

4. Fluid volume deficit. Fluid volume deficit (dehydration) can lead to circulatory impairment and hyperkalemia.

The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin.

4. Notify the HCP to obtain an order to decrease insulin. When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale.

The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warmup and cool-down exercises.

4. Perform warmup and cool-down exercises. All clients who exercise should perform warmup and cool-down exercises to help prevent muscle strain and injury.

Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the client's fluid intake to 1,000 mL/day. 4. Provide six (6) small, well-balanced meals a day.

4. Provide six (6) small, well-balanced meals a day. The client with hyperthyroidism has an increased appetite; therefore, wellbalanced meals served several times throughout the day will help with the client's constant hunger.

Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24. 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22. 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26. 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.

4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18. This ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis.

Which patient does the nurse recognize as being most likely to be affected by sickle cell disease? A. A 14 yr old African American boy B. A 26 yr old Eastern European Jewish woman C. An 18 yr old Chinese woman D. A 28 yr old Israeli man

A. A 14 yr old African American boy

The nurse is educating a patient with iron deficiency anemia how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance absorption? A. Eating calf's liver with a glass of orange juice B. Eating leafy green vegetables with a glass of water C. Eating apple slices with carrots D. Eating a steak with mushrooms

A. Eating calf's liver with a glass of orange juice

A patient with sickle cell anemia is to begin treatment for the disease with hydroxyurea. What does the nurse inform the patient will be the benefits of treatment with this medication? (select all that apply) A. Fewer painful episodes of sickle cell crisis B. Lower incidence of acute chest syndrome C. Decreased need for blood transfusions D. Decreased need for other analgesic medications E. Ability to reverse the damage done from sickling of cells

A. Fewer painful episodes of sickle cell crisis B. Lower incidence of acute chest syndrome C. Decreased need for blood transfusions

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the physician. What type of anemia is the nurse concerned the co-worker may have? A. Iron deficiency anemia B. Megaloblastic anemia C. Sickle cell anemia D. Aplastic anemia

A. Iron deficiency anemia

A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohns disease. The patient has developed lymphopenia with a lymphocyte cout of less than 1,500 mm3. What should the nurse monitor the client for? A. The onset of a bacterial infection B. Bleeding C. Abdominal pain D. Diarrhea

A. The onset of a bacterial infection

A patient with sickle cell disease is brought to the emergency department by a parent. The patient has a fever of 101.6 F, HR of 116, and RR of 32. The nurse auscultates bilateral wheezes in both lung fields. What does the nurse suspect this patient is experiencing? A. Pneumocystis B. Acute chest syndrome C. An exacerbation of asthma D. Pulmonary edema

B. Acute chest syndrome

The nurse is assessing a patient who comes to the clinic complaining of feeling constantly tired and very weak. The patient also has a very sore tongue, and upon observing the patient's oral cavity, the nurse notices the tongue is beefy red. What type of anemia does the nurse know these symptoms indicate? A. Iron deficiency anemia B. Megaloblastic anemia C. Sickle cell anemia D. Aplastic anemia

B. Megaloblastic anemia

The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive dose of B12. What test is the patient being prepared for? A. Bone marrow aspiration B. Schilling test C. Bone marrow biopsy D. Magnetic resonance imaging (MRI) study

B. Schilling test

A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms? A. Thiamine B. Folate C. B12 D. Iron

C. B12

A patient with ESRD is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? A. Potassium level B. Creatinine level C. Hemoglobin level D. Folate levels

C. Hemoglobin level

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? A. It is part of the required assessment information B. It is important for the nurse to determine what types of foods the patient will eat C. It may indicate deficiencies in essential nutrients D. It will determine what type of anemia the patient has

C. It may indicate deficiencies in essential nutrients

The nurse is assessing a patient who is a strict vegetarian. What type of anemia is the nurse aware that this patient is at risk for? A. Iron deficiency anemia B. Aplastic anemia C. Megaloblastic anemia D. Sickle cell anemia

C. Megaloblastic anemia

A patient with sickle cell disease comes to the emergency department complaining of severe pain in the back, right hip, and right arm. What intervention is important for the nurse to provide? A. administer aspirin B. Administer ibuprofen C. Start an intravenous line with dextrose 5% in 0.24 normal saline D. Begin oxygen at 2L/min

C. Start an intravenous line with dextrose 5% in 0.24 normal saline

A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia? A. Potassium lvl of 5.2 mEq/L B. Magnesium lvl of 2.5 mg/dL C. Calcium lvl of 9.4 mg/dL D. Creatinine lvl of 6mg/100mL

D. Creatinine lvl of 6mg/100mL

A patient had gastric bypass surgery 3 years ago and now, experiencing fatigue, visits the clinic to determine the cause. The patient takes pantoprazole for the treatment of frequent heartburn. What type of anemia is this patient at risk for? A. Aplastic anemia B. Iron deficiency anemia C. Sickle cell anemia D. Pernicious anemia

D. Pernicious anemia

The client diagnosed with Cushing's disease has developed 1+ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received IVPB medication in 50 mL of fluid every 6 hours for 15 doses. How many mL of fluid did the client receive? ________

The client has received 8,650 mL of intravenous fluid.

The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6) units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client? _________

Three (3) units. The client's result is 189, which is between 151 and 200, so the nurse should administer 3 units of Humalog insulin subcutaneously.

The health-care provider has ordered 40 g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10 g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time? ______

Two (2) sprays per dose.