Quizzes for Exam 2

A nurse is assessing a child suspected of having type 1 diabetes mellitus (DM). Which question should the nurse ask the parents to validate the diagnosis? "Has the child gained a lot of weight?" "Does the child have urinary frequency?" "How much exercise does the child get?" "Does the child complain of headaches?"

"Does the child have urinary frequency?" The 3 P's that the nurse should ask when evaluating a client for DM polydipsia, polyuria, and polyphagia

A client who is in halo traction states to the visiting nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which therapeutic response would the nurse make to the client? "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around." "Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think? "If I were you, I would have had the surgery rather that suffer like this." "No one ever gets used to that thing! It's horrible. Many of our sports people who are in it complain vigorously."

"Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around."

The nurse is caring for a client newly diagnosed with Hypothyroidism and teaching about Levothyroxine. The client requires further teaching when they state which of following? "While I love seafood, I need to make other food choices." "I am glad my breakfast is here so I can take my thyroid medication right before I eat." "I took my thyroid medication 30 minutes ago, so now I am able to eat." "Kelp is not good for me when taking this medication."

"I am glad my breakfast is here so I can take my thyroid medication right before I eat."

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? "I need to call the health care provider (HCP) because of these symptoms." "I need to monitor my blood glucose every 3 to 4 hours." "I need to stop my insulin." "I need to increase my fluid intake."

"I need to stop my insulin." Insulin should never be stopped immediately. Without insulin, the body cannot access enough sugar to function properly, so your liver begins to turns some of the body fat into acids called ketones. These build up in the bloodstream and spill over into the urine.

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? "I will use a straw for drinking." "I will be careful because the device alters balance." "I will drive only during the daytime." "I will wash the skin daily under the lamb's wool liner of the vest."

"I will drive only during the daytime."

The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? "I will take a brisk 30-minute walk 3-5 days per week three times a week." "I will go running each day when my blood sugar is too high to bring it back to normal." "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." "I will plan to keep my job as a teacher because I get a lot of exercise every school day."

"I will take a brisk 30-minute walk 3-5 days per week three times a week."

A client has fallen and sustained a leg injury. Which question would the nurse ask to help determine if the client sustained a fracture? "Does the pain feel like the muscle was stretched?" "Is the pain sharp and continuous?" "Does the discomfort feel like a cramp?" "Is the pain a dull ache?"

"Is the pain sharp and continuous?"

The nurse is caring for a client with Type I Diabetes Mellitus. When asked by the client why she is so thirsty all the time, how should the nurse respond? "Osmotic fluid shifts cause excessive urine output and leads to dehydration and thirst" "Due to your resistance to insulin, metabolism and nutritional requirements are increased." "Increased blood glucose levels decrease serum osmolality and trigger thirst receptors" "Due to your insulin deficiency, your cells become starved causing increased appetite and thirst"

"Osmotic fluid shifts cause excessive urine output and leads to dehydration and thirst" A patient with Type I DM complaining of feeling thirsty all the time is related to the osmotic fluid shifts causing excessive urine output, leading to to dehydration and thirst

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? "The drug prevent clots from forming in the legs during your recovery from surgery." "This medicine is given to help your body respond to stress after removal of the adrenal glands." "This drug stimulates your immune system and promotes wound healing." "The medication prevents sodium and water retention after surgery."

"This medicine is given to help your body respond to stress after removal of the adrenal glands."

How many drops per minute will you infuse if the order reads: "Infuse 3/4 L of D5W over 5 hours and 45 minutes". The drop factor is 60 gtts/mL. Fill in the blank and record your final answer to the nearest whole number.

130 Use the IV flow rate formula for gtts/minute above. Multiply 750 ml (total infusion volume) to 60 gtt/ml (drop factor) to get 45,000. To get the total infusion time in minutes, multiply 5 hours to 60 minutes to get 300 minutes, then add 45 minutes to a total of 345 minutes. Divide 45,000 by 345 minutes to get 130.43 gtts/minute. Finally, round off to a whole number to get 130 gtts/minute.

At the change of shift, you notice 200 ml left to count in your patient's IV bag. The IV is infusing at 80 ml/hr. How much longer in hours will the IV run? Fill in the blank and record your final answer using one decimal place.

2.5 Divide 200 ml with 80 ml/hr to get 2.5 hours or 2 1/2 hours.

You have on hand morphine 500 mg in 500 mL normal saline. You need to administer morphine 80 mg/hour in a continuous IV infusion to a patient with terminal cancer pain. How many milliliters per hour will you set on the controller? Fill in the blank and round to the nearest whole number for your final answer.

80

Your OWN words, describe how you would teach your patient how to properly manage their diabetes. (Physical activity, psychosocial, disease process, diet. Etc.)

A regular and consistent plan to even just start walking to increase your movement can be beneficial. Active house work dancing, or even gardening is a great start. There is more than one way to approach a meal plan. Start with appropriate serving sizes, a reduction of saturated and trans fats, and low carbohydrates can decrease calorie consumption. Spacing meals is another strategy that spreads nutrient intake throughout the day. Its important to have a good support system in place for her psychosocial. Referrals for DM education might be a great resource for her to get more information and advice as well. Page 1123 in Lewis

Paralysis from the damaged cellular structures (neurons) in a client with a spinal cord injury may affect: (choose all that apply) Bladder and Bowel function Mobility Sexual function Sensation

ALL are correct

Your OWN words explain a few reasons why we screen for diabetes in asymptomatic persons.

According to page 1111 in our Lewis online text states, people with prediabetic usually don't have symptoms. We screen because long-term damages can already be happening even if the pts. don't feel it. Completing the screening helps to understand risk factors for diabetes. People with prediabetes can take action to prevent or delay the development of type 2 diabetes

The nurse is caring for a client with a diagnosis of Cushing's syndrome with a history of anterior pituitary tumor. The nurse will assess for which of the following characteristics of Cushing's syndrome? Select all that apply. Acne Round face Swelling of feet and legs Hyperactive state Weight loss

Acne Round face Swelling of feet and legs

Exophthalmos is a common finding among patient with hyperthyroidism. What can the nurse do to help the patient with this condition? Select all that apply. Administer artificial tears for comfort Provide a warm blanket tape eyelids closed at night if necessary encourage the use of dark glasses

Administer artificial tears for comfort tape eyelids closed at night if necessary encourage the use of dark glasses Exophthalmos is the protrusion of the eyes that can cause dryness and discomfort. Artificial tears can provide local comfort as well as encouraging the use of dark glasses. If the patient cannot sleep because they are unable to close their eyelids the nurse can offer taping the eyelids closed at night, as necessary. Elevating the head of the bed and instructing on a low-salt diet are also important in caring for a patient with exophthalmos.

A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle would the nurse expect the client to report? Amenorrhea Metrorrhagia Menorrhagia Dysmenorrhea

Amenorrhea

The nurse is managing a client with DKA. Which management intervention is incorrect in the management of a client with DKA? Assess potassium levels 2 hours after treatment because potassium shifts affect the heart Administer regular insulin as ordered Infuse Normal Saline (0.9%) to replace fluid loss Assess vital signs and monitor ketone levels

Assess potassium levels 2 hours after treatment because potassium shifts affect the heart Assessing potassium levels 2 hours after treatment is incorrect as every 2 hours is too long in time. Potassium levels should be monitored, ongoing, as potassium shifts can affect the heart during the DKA episode. Administering regular insulin as ordered and assessing vital signs and monitoring ketone levels are very important in caring a DKA patient.

The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse would determine that there is a need for close observation and a need for follow-up if which is noted? Capillary refill greater than 6 seconds Blanching of the nail bed when it is depressed Sensation when the area distal to the cast is pinched Palpable pulses distal to the cast

Capillary refill greater than 6 seconds

During the postoperative period, the client who underwent a hip replacement reports pain the calf area. What action would the nurse take? Check the calf area for temperature, color, and size Lightly massage the calf area to relieve the pain Administer as needed (PRN) morphine sulfate as prescribed for postoperative pain Ask the client to walk and observe the gait

Check the calf area for temperature, color, and size

The nurse is performing pin-site care on a client in skeletal traction. Which normal finding would the nurse expect to note when assessing the in sites? Redness and swelling around the pin sites Warm skin around the pin sites Numbness at the pin sites Clear drainage from the pin sites

Clear drainage from the pin sites

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client's anxiety? Ignore the signs and symptoms of anxiety, anticipating that they will son disappear. Administer a sedative. Convey empathy, trust, and respect toward the client. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening.

Convey empathy, trust, and respect toward the client.

List 3 differences between HHS and DKA? List the page number where you found the information.

DKA is mostly seen in DM type 1 HHS an occur in the patient with diabetes who is able to make enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion. HHS is less common than DKA The main difference between HHS and DKA is that the patient with HHS usually has enough circulating insulin so that ketoacidosis does not occur. Because HHS has fewer symptoms in the earlier stages, blood glucose levels can climb quite high before the problem is recognized. Hypokalemia is not as significant in HHS as it is in DKA, although fluid losses may result in milder potassium deficits that require replacement.

A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which priority action should the nurse advise her to take? Take an extra dose of rapid-acting insulin Drink some diet pop Eat 15 g of simple carbohydrates Eat a piece of cheese pizza

Eat 15 g of simple carbohydrates The "rule of 15" is commonly used as a guideline for treatment: After checking your blood glucose level with your meter and seeing that your level is under 70 mg/dl, consume 15 grams of carbohydrate, wait about 15 minutes, then recheck your blood glucose level.

A client who has had Addison's disease for 20 years and has been in the ICU following an event where he was found unconscious due to Addisonian crisis is being discharged home. Which discharge teaching is priority for the client? Explain the side effects of taking hydrocortisone Help the client understand what Addison's disease is Show the patient how to daily check his blood pressure Explain the importance of wearing medical alert bracelet

Explain the importance of wearing medical alert bracelet A client who has had Addison's disease for 10 years and was recently found unconscious from Addisonian crisis should be reminded about the importance of wearing medical alert jewelry. This helps emergency personnel be able to treat him immediately if found unable to communicate.

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder may be developing. Select all that apply. Lethargy Bradycardia Fever and Nausea Tremors and Confusion

Fever and Nausea Tremors and Confusion Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking? Left leg discomfort Forearm muscle weakness Triceps muscle weakness Weak biceps brachii

Forearm muscle weakness

The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control within the last 3 months?

Glycosylated hemoglobin level (HgA1c)

A patient has an infection and reports not checking their blood glucose or regularly taking Metformin. What condition is this patient MOST at risk for? DKA Metabolic acidosis HHNS Metabolic alkalosis

HHNS

In a client with Graves Disease, which clinical manifestation would the nurse expect a client to report? Bradycardia Lethargy Cold, clammy skin Heat Intolerance

Heat Intolerance

The nurse is assessing a client admitted with Addison's Disease. Assessment findings consist of generalized muscular weakness, hypotension, irritability, and hyperpigmentation of skin. Which lab values would the nurse expect to find? Elevated cortisol level Hyperkalemia, hypercalcemia Elevated glucose level Hypokalemia, hypocalcemia

Hyperkalemia, hypercalcemia This answer is correct because Addison's disease is a rare, yet serious disorder of the adrenal gland. Dysfunction of the adrenal glands causes decreased production of cortisol and aldosterone in the body. Electrolyte imbalance (e.g., hyperkalemia, hypercalcemia, and hyponatremia) may occur and may be triggered from stress, trauma, or surgery. Assessment findings consist of generalized muscular weakness, hypotension, irritability, and hyperpigmentation of skin. The client should be taught the necessity of lifelong steroid replacement therapy.

The nurse is preparing to administer subcutaneous insulin to a client with hyperglycemia. The nurse will monitor the client's lab work closely for which electrolyte imbalance related to insulin administration? Hyperkalemia Hyponatremia Hypocalcemia Hypokalemia

Hypokalemia Insulin puts glucose and potassium into the cell. Potassium is the electrolyte to monitor; specifically, for hypokalemia. Potassium is going from the blood, into the cell, causing hypokalemia.

The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? "I like when I go out to eat dinner with my husband because I enjoy wearing my high heels." "I should only walk barefoot in nice dry weather." "I am lucky my shoes fit so nice and tight because they give me firm support." "I should look at the condition of my feet every day."

I should look at the condition of my feet every day."

Levothyroxine can be administered multiple routes. Which of the following are acceptable routes to give this medication? PO and subcutaneously IV and PO IV and Subcutaneously IV and rectally

IV and PO PO is the most common route. For patients in a Myxedema coma, IV is given routinely to increase serum levels quickly to reverse this condition.

After a cervical spine fracture, this device (refer to figure) is placed on the client. The nurse creates a discharge plan for the client to ensure safety and includes which measures? Select all that apply. Instruct the client to bend at the waist to pick up needed items Inform the client about the importance of wearing rubber-soled shoes. Demonstrate the procedure for scanning the environment for vision Teach the client how to ambulate with a walker Teach the spouse to use the metal frame to assist the client to turn in bed

Inform the client about the importance of wearing rubber-soled shoes. Demonstrate the procedure for scanning the environment for vision Teach the client how to ambulate with a walker

The nurse is preparing a client diagnosed with Graves' disease to receive radioactive iodine therapy. What information would the nurse share with the client about the therapy? It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease. The radioactive iodine is designed to destroy the entire thyroid gland with just one dose. High radioactivity levels prohibit contact with family for 4 weeks after the initial treatment After the initial dose, subsequent treatments must continue lifelong.

It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease.

A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information would the nurse provide to the client to prevent complications? Weight bearing on the right leg is allowed once the cast feels dry Keep the right ankle elevated above the heart level with pillows for 24 hours Trim the rough edges of the cast after it is dry Expect burning and tingling sensations under the cast for 3 to 4 days

Keep the right ankle elevated above the heart level with pillows for 24 hours

A client in a car accident arrives in the emergency department with a hip dislocation. The nurse places the client in Buck's traction. Which interventions are priority when placing Buck's traction on a client? Select all that apply. Keep weights free hanging at all times with tight traction ropes Release the free hanging weights on the traction every hour Keep the client's HOB at 45-90 degrees at all times Do not elevate HOB over 25 degrees at all times perform neuro checks every hour on affected extremity Position the client in side-lying position at all times

Keep weights free hanging at all times with tight traction ropes Do not elevate HOB over 25 degrees at all times perform neuro checks every hour on affected extremity

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply Limiting bladder catheterization to once every 12 hours Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours Ensuring that the client has a bowel movement at least once a week

Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours

The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? Mild to moderate incisional pain Laryngeal stridor Abdominal cramps Difficulty in voiding

Laryngeal stridor During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration; stridor is caused by compression of the trachea, leading to respiratory distress. Stridor is an acute emergency situation that requires immediate attention to avoid complete obstruction of the airway.

A client is admitted to an emergency department and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? Warm the client Maintain a patent airway Administer fluid replacement Administer IV thyroid hormone replacement

Maintain a patent airway

A nurse is caring for a client with a C5 spinal injury. Which action is most important for a client with injury to the C5 spinal cord? Apply an abdominal binder Monitor client's respiratory status Monitor signs of infection Encourage the use of incentive spirometer

Monitor client's respiratory status

The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of cast. Postoperatively, which nursing assessment is of highest priority to assure client safety? Monitoring for blanching ability of toe nail beds Monitoring for extremity shortening Monitoring for heel breakdown Monitoring for bladder distention

Monitoring for blanching ability of toe nail beds

A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis? Hypovolemia Mood disturbances Deficient fluid volume Hypoglycemia

Mood disturbances

The nurse is preparing a teaching plan for a client who had a total left hip replacement. Which interventions should be included in the client's teaching plan? Select all that apply. No sitting in a chair at 90 degrees Lie on affected hip when in bed Pivot on the affected hip/leg when transferring Do not lean forward Do not cross the legs Abduct the legs

No sitting in a chair at 90 degrees Do not lean forward Do not cross the legs Abduct the legs

Which medication instructions would the nurse provide to a client who has been prescribed levothyroxine? Select all that apply. Scroll down to review the 6 different answer choices. Notify the primary health care provider if chest pain occurs. Take the medication at the same time each day. Take the medication in the morning. It may take 1 to 3 weeks for a full therapeutic effect to occur. Expect the pulse rate to be greater than 100 beats/min. Monitor your own pulse rate.

Notify the primary health care provider if chest pain occurs. Take the medication at the same time each day. Take the medication in the morning. It may take 1 to 3 weeks for a full therapeutic effect to occur. Monitor your own pulse rate.

Which of the following is not a sign or symptom of Diabetic Ketoacidosis? Positive ketones in the urine Abdominal pain Polydipsia Oliguria

Oliguria Oliguria means low urinary output...in DKA there is POLYURIA (high urinary output)

You are providing care to a patient experiencing diabetic ketoacidosis. The patient is on an insulin drip and their current glucose level is 300. In addition, to the insulin drip the patient also has 5% Dextrose 0.45% NS infusing in the right antecubital vein. Which of the following patient signs/symptoms causes the most concern? Patient complains of thirst Patient is nauseous Patient has a potassium level of 2.3 Patient's skin and mucous membranes are dry

Patient has a potassium level of 2.3 This indicates hypokalemia, which could be life-threatening.

The nurse is caring for a client with spinal cord injury and is preparing an instructional plan for the client and family on autonomic dysreflexia. Which teaching promotes the best measure to minimize occurrence of autonomic dysreflexia? Use nitroglycerin ointment for low blood pressure Perform bladder catheterization at least every 4 hours Perform ranges of motion at least 4 times per day Perform bladder catheterization once each 12 hours

Perform bladder catheterization at least every 4 hours

A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include: Releasing the traction for five minutes each shift Loosening the pins if the client complains of headache Elevating the head of the bed 90o Performing sterile pin care as ordered

Performing sterile pin care as ordered

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply Persistent lethargy Puffiness of the face Tremors and weight loss Loss of body hair and feeling cold

Persistent lethargy Puffiness of the face Loss of body hair and feeling cold Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism

A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? Ask the patient about home insulin doses Start an insulin infusion at 0.1 units/kg/hr Place the patient on a cardiac monitor Administer IV potassium supplements

Place the patient on a cardiac monitor Placing a patient with DKA on a cardiac monitor must be done first to assess their cardiac rhythm. Starting and insulin infusion and administering IV potassium supplements is next

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply. Polyuria Headache Bone pain Weight gain

Polyuria Bone Pain The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with Hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain.

The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection? Coolness and pallor of the skin Diminished distal pulse Dependent edema Presence of warm areas on the cast

Presence of warm areas on the cast

The nurse is providing education to a 50-year-old client with newly diagnosed type II diabetes mellitus. Which will the nurse include in teaching? Low blood glucose is best treated with high sugar and fatty snacks like peanut butter, crackers and whole milk Proper diet and exercise can reduce the signs and symptoms of type II diabetes mellitus Feelings of excess hunger and thirst mean that blood sugar has dropped Type II diabetes will be managed entirely with subcutaneous insulin

Proper diet and exercise can reduce the signs and symptoms of type II diabetes mellitus

The nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, would perform a complete neurovascular assessment of the affected extremity that includes which interventions. Select all that apply. Pulse in the affected extremity Skin color of the affected extremity Level of pain in the affected leg Bilateral lung sounds Capillary refill of the affected toes

Pulse in the affected extremity Skin color of the affected extremity Level of pain in the affected leg Capillary refill of the affected toes

A client with a spinal cord injury is at risk of developing footdrop. What intervention would the nurse use as a preventive measure? Mole skin-lined heel protectors Regular use of posterior splints or high-top sneakers Avoiding dorsal flexion of the foot Application of pneumatic boots

Regular use of posterior splints or high-top sneakers

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Respirations that are shallow Respirations that are abnormally deep and increased in rate Respirations that are abnormally slow Respirations that cease for several seconds

Respirations that are abnormally deep and increased in rate Kussmaul's respirations has the pattern of rapid, deep breathing associated with dyspnea. This is the body's attempt to reverse metabolic acidosis through the exhalation of excess CO2, occurring in DKA patients.

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? Edema at the surgical site Level of hoarseness Respiratory distress Hypoglycemia

Respiratory distress

A client has a hip fracture repair with a prosthetic implant placed. On the day after the implant, the nurse finds the client surrounded by papers from his briefcase and planning a phone meeting. The nurse plans to discuss activities with the client and would base the discussion on which information? Not keeping up with his job will increase the client's stress level Rest is an essential component of bone healing. Setting limits on a client's behavior is a mandated nursing role Involvement in his job will keep the client from becoming bored

Rest is an essential component of bone healing.

A client has had type 2 diabetes for the past 5 years and is admitted for a myocardial infarction. The client is concerned about having another MI and is asking what caused this one. Which would be high priority when discussing diabetes management practices and the risks of another MI? Choose all that apply. Reviewing prior blood glucose records Checking foot care practices Reviewing prior blood pressure readings Determirmining treatment for hypoglycemia

Reviewing prior blood glucose records Reviewing prior blood pressure readings Diabetes mellitus and hypertension are common diseases that coexist at a greater frequency than chance alone would predict. Hypertension in the diabetic with uncontrolled blood sugar levels and uncontrolled blood pressure are at risk for an MI.

What statement or statements are INCORRECT regarding Diabetic Ketoacidosis? Ketones are present in the urine in DKA. Severe hypoglycemia is a hallmark sign in DKA. DKA occurs mainly in Type 1 diabetics. Cheyne-stokes breathing will always present in DKA.

Severe hypoglycemia is a hallmark sign in DKA. Cheyne-stokes breathing will always present in DKA.

Which of the following methods would be the preferred method to use when performing physical assessment (palpation) of the thyroid gland? Stand in front of the client, place fingers slightly above the thyroid cartilage, have the client extend the head and swallow Stand in front of the client, place fingers above the trachea, have the client flex the head, and ask the client to swallow Stand behind the client, place the fingers above the jugular notch, have the client extend the head and swallow Stand behind the client, place the fingers on either side of the trachea below the thyroid cartilage, have the client tilt the head to the right and swallow

Stand behind the client, place the fingers on either side of the trachea below the thyroid cartilage, have the client tilt the head to the right and swallow

The nurse is assessing a diabetic client one hour after administration of a dose of subcutaneous insulin. Which finding(s) alert the nurse that the client may be experiencing hypoglycemia? Elevated body temperature and agitation Bradycardia and fatigue Reports of hunger and excess urination Tachycardia and new restlessness

Tachycardia and new restlessness Hypoglycemia is a BLG ≤ 70. Clinical manifestations include: cool pale "pallor" skin, diaphoresis, hunger, tachycardia, headache, irritability, weakness, anxiousness, restlessness, and trembling. Hunger and excess urination are signs of hyperglycemia.

The nurse is caring for a client who is recovering from a T1 spinal cord injury. Which is the best explanation by the nurse to the client and family on the ability for motor function in relation to spinal cord injury? The shoulder may be mobile and shrug, but the arms below the shoulder will be paralyzed There will be completely loss of mobility with paralysis from neck down There will be risks of respiratory depression due to the location of injury The arm will retain their full function

The arm will retain their full function

A client is admitted to the orthopedic unit with an external fixator due to a fractured humerus. Which of these findings should alert the nurse to call the health care provider (HCP) immediately? Select all that apply. The client becomes confused, restless with dyspnea The client has a temp of 101.8 degrees The client's WBC count is 9.0ul The client's hemoglobin is 7.1 gm/dL The skin around the insertion site of fixator is draining green exudate

The client becomes confused, restless with dyspnea The client has a temp of 101.8 degrees The client's hemoglobin is 7.1 gm/dL The skin around the insertion site of fixator is draining green exudate

Describe how diabetic ketoacidosis could develop in a patient with Type 1 DM, who has undergone surgery.

The increase of stress from the surgery can cause the glucose level to rise. The stress response to surgery and the resultant hyperglycemia, osmotic diuresis, and hypoinsulinemia can lead to perioperative ketoacidosis or hyperosmolar syndrome. In a patients with Type I DM who have surgery, they may experience extra stress in the body or could be developing an infection, which would cause ketoacidosis.

The nurse is caring for a client who has been given radioactive iodine for the treatment of their hyperthyroidism. The patient vomits after treatment. The nurse knows which important information regarding the emesis from this patient? The nurse needs to proceed with caution because the emesis is radioactive The emesis needs to be cleaned as it is a danger to the patient This is not a common occurrence and the HCP must be notified immediately The patient is fine and there is no immediate danger to the patient or the nurse

The nurse needs to proceed with caution because the emesis is radioactive

The nurse gives corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? The patient's lung sounds are clear The patient's potassium level is 5.7 mEq/L The patient is alert and oriented The patient's urinary output decreases

The patient is alert and oriented

The nurse is caring for a patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed? The patient makes harsh, vibratory sounds when breathing The patient reports a sore throat when swallowing The patient reports of increased thirst The patient supports her head when moving in bed

The patient makes harsh, vibratory sounds when breathing After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). Emergency equipment should be at the bedside, including oxygen, suction equipment, and a tracheostomy tray.

The nurse is caring for a patient with hypothyroidism. The patient states they have been taking their thyroid medication as prescribed but states they are now experiencing fatigue, brittle nails, dry hair, dry skin and feeling cold. They also share they have 10 pounds of unexplained weight gain. The nurse suspects which of the following? The patient is exaggerating and needs to be told this is normal The patient is not telling the truth about taking their medication as prescribed The patient may need to stop taking their medication The patient may need an adjustment in their medication

The patient may need an adjustment in their medication Occasionally, patient may need an adjustment in their medication. These clinical manifestations should be reported to the HCP. An increase in their medication is needed and will be ordered by the HCP. These clinical manifestations improve significantly after 3 months of taking their thyroid medication of the appropriate dose and should only return during an exacerbation of the condition.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? Redness around the pin sites Thick, yellow drainage from the pin sites Clear, watery drainage from the pin sites Pain on palpation at the pin sites

Thick, yellow drainage from the pin sites

Propranolol can be given during a thyroid storm. Why would this medication be indicated? This can be given to decrease sympathetic stimulation created by the body It helps to increase T4 levels It helps the patient with exophthalmos This can be given to increase parasympathetic stimulation

This can be given to decrease sympathetic stimulation created by the body Propranolol is a beta blocker that reduces the sympathetic response.

Thyroid storm is an acute and life-threatening condition that occurs in clients with uncontrollable hyperthyroidism. True False

True

When asked by a new graduate about the etiology of Type II diabetes mellitus, how does the nurse respond? Clients with type II diabetes mellites require lifelong subcutaneous insulin replacement Type II diabetes melltus is an autoimmune disorder in which the beta cells of the pancreas doesn't produce insulin Type II diabetes mellitus results from surgical removal of the pancreas Type II diabetes mellitus results from a resistance to circulating insulin

Type II diabetes mellitus results from a resistance to circulating insulin Type II diabetes mellitus results from a resistance to circulating insulin. Clients with Type II DM doe NOT require lifelong subcutaneous insulin replacement. Type I DM is an autoimmune disorder, not type II DM. The pancreas is NEVER removed for diabetes, so this answer is incorrect.

he nurse is caring for a client admitted for diabetic ketoacidosis (DKA). Which is the priority assessment for clients with this diagnosis? Urine output Equality of radial pulses Rectal temperature Daily weights

Urine output n DKA, the patient has high sugar level from 250-500, ketones are noted in the urine, they present with Kussmaul respirations, fruity breath smell, abdominal pain and a pH 7.35 or less. Urine output is the highest assessment and priority to evaluate if the patient is becoming dehydrated. Daily weight track water retention, but we need to track I & O's very closely for early intervention.

The nurse prepares to transfer the client with a newly applied leg cast into the bed using which method? Using the palms of the hands and soft pillows to support the cast Supporting the cast with the fingertips only Asking the client to support the cast during transfer Placing ice on top of the cast

Using the palms of the hands and soft pillows to support the cast

The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction? Drainage at the pin sites Weak pedal pulses Complaints of leg discomfort Toes are warm and demonstrate a brisk capillary refill

Weak pedal pulses

Which of the following is not a symptom of hyperglycemia? Polyuria Polydipsia Polyphagia Weight gain

Weight gain Clinical manifestations of hyperglycemia include the 3 P's: polydipsia, polyuria and polyphagia. Weight gain is not a sign of hyperglycemia.

The nurse is assessing a client diagnosed with hyperosmolar hyperglycemia nonketotic syndrome (HHNS). Which manifestation(s) does the nurse expect? Weight loss, increased urine output, hyperglycemia Increased urine output, dehydration, metabolic acidosis Hyperglycemia, ketoacidosis, decreased urine output Weight gain, respiratory acidosis, hyperkalemia

Weight loss, increased urine output, hyperglycemia HHNS: Blood sugar over 600+, extreme dehydration related to fluid loss, confusion, NO abdominal pain, NO Ketones, weight loss, increased urine output, and hyperglycemia are the clinical manifestations for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). They will not have Kussmaul breathing and will not be acidic. Potassium levels will be stable.

The nurse witnesses a client who fell and sustained a compound fracture to the left arm. Which nursing intervention is the priority to take with this type of fracture? Wrap the fracture arm with compression bandage Attempt to manually reduce the fracture Wrap the fracture with sterile gauze and Merlin Keep the fractured arm below level of heart

Wrap the fracture with sterile gauze and Merlin

The nurse is caring for a patient who has a history of hyperthyroidism, and notes in their chart, that they take Levothyroxine. Is this possible? No, this is unusual and the medication should be held and not given Yes, it is common for the patient to take thyroid replacements Yes, because this helps with Chvostek and Trousseau's sign. No, the patient is lying and their chart may be wrong as they have hypothyroidism

Yes, it is common for the patient to take thyroid replacements Patients who have hyperthyroidism usually have treatment for this condition that create a hypothyroidism state afterwards such as a total thyroidectomy, thyroid ablation with medication and radioactive iodine. The patient who once had hyperthyroidism is now a hypothyroid patient and needs to have this medication to stabilize their new state.

The nurse is checking the laboratory results of an adult client with type 1 diabetes (see below). What laboratory result indicates a problem that should be managed? Blood glucose: 192mg/dL Total cholesterol: 201 mg/dL Hemoglobin: 12.3 mg/dL Low-density lipoprotein (LDL) cholesterol: 125 mg/dL

blood glucose The normal range for blood glucose is 70 to 110 mg/dL; the elevated blood glucose level indicates hyperglycemia. The other results are within normal limits.

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120mg/dL. The nurse will first plan to teach the patient about _____. effects of oral hypoglycemic medications using low doses of regular insulin lifestyle changes to lower blood glucose self-monitoring of blood glucose

lifestyle changes to lower blood glucose Teaching the client about lifestyle changes to lower blood glucose is the first topic to be taught so it can be evaluated for a possible change at the next visit.

Myxedema coma can be precipitated by which of the following? Select all that apply. Scroll down to see the 5 answer choices. rapid withdrawal of thyroid medication use of sedatives and opioid analgesics anesthesia and surgery acute illness hyperthermia

rapid withdrawal of thyroid medication use of sedatives and opioid analgesics anesthesia and surgery acute illness

Thyroid storm can be caused by the following: Select all that apply. stress controlled hyperthyroidism manipulation of the thyroid gland during surgery and the release of thyroid hormone into the bloodstream severe infection

stress manipulation of the thyroid gland during surgery and the release of thyroid hormone into the bloodstream severe infection Thyroid storm can be caused by manipulation of the thyroid gland during surgery and the release of thyroid hormone into the bloodstream; it also can occur from severe infection and stress. It occurs in client with uncontrollable hyperthyroidism, not controlled hyperthyroidism.