Nokea
A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
- A. Hyperglycemia
- B. Hyperuricemia
- C. Hypoglycemia
- D. Hypochondria
Correct Answer: C
Rationale: The correct answer is C: Hypoglycemia. At 4:30 p.m., after taking the morning insulin, the client's blood sugar may have dropped too low, leading to symptoms like headache, sweating, tremor, pallor, and nervousness. Regular insulin and NPH insulin peak at different times, causing a potential mismatch in insulin action, leading to hypoglycemia. Hyperglycemia (A) would present with different symptoms like increased thirst and urination. Hyperuricemia (B) is an excess of uric acid in the blood and does not typically present with these symptoms. Hypochondria (D) is a psychological condition and not related to the client's physical symptoms.
You may also like to solve these questions
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
- A. “Take zidovudine with meals.”
- B. “Take zidovudine on an empty stomach.”
- C. “Take zidovudine every 4 hours around the clock.”
- D. “Take over-the-counter(OTC) drugs to treat minor adverse reactions.”
Correct Answer: C
Rationale: The correct answer is C: "Take zidovudine every 4 hours around the clock." Zidovudine is an antiretroviral medication used to treat HIV/AIDS. It is crucial for the client to adhere to the prescribed dosing schedule to maintain therapeutic blood levels. Taking the medication every 4 hours around the clock helps to ensure consistent levels in the body, maximizing its efficacy. Taking it with meals (choice A) or on an empty stomach (choice B) is not specifically indicated for zidovudine. Choice D is incorrect as taking OTC drugs without consulting a healthcare provider can lead to drug interactions or adverse effects. Hence, choice C is the most appropriate instruction to ensure the client benefits from the medication.
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
- A. A sudden raise in BP may occur during the first 1-3 hours after the initial dose
- B. A sudden drop in BP may occur during the first 1-3 hours after the initial dose
- C. A sudden drop in body temperature may occur during the first 1-3hours after the initial dose
- D. A sudden rise in pulse rate may occur during the first 1-3 hours after the initial dosage CARING WITH CLIENTS WITH CEREBROVASCULAR DISORDER
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications.
Incorrect choices:
A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors.
C: Angiotensin converting enzyme inhibitors do not affect body temperature.
D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate.
In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.
What is the last step when inserting an IV cannula?
- A. Secure the cannula with tape.
- B. Document the insertion site, date, and type of cannula used.
- C. Assess the site
- D. Place a sterile dressing over the insertion site. INFLAMMATORY AND INFECTIOUS DISTURBANCES Caring for clients with upper respiratory infections
Correct Answer: A
Rationale: The correct answer is A: Secure the cannula with tape. This is the last step in inserting an IV cannula to ensure it stays in place and prevents dislodgement or movement. Securing the cannula with tape helps maintain proper positioning and prevents accidental removal. Documenting the insertion site, date, and type of cannula used (B) is important but typically done earlier in the process. Assessing the site (C) should be done before securing the cannula to ensure proper placement. Placing a sterile dressing over the insertion site (D) is also important, but it usually comes before securing the cannula with tape to maintain a clean and sterile environment.
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
- A. Assist the patient to walk in the room with crutches.
- B. Obtain a walker for the patient.
- C. Consult physical therapy.
- D. Administer pain medication.
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery.
Explanation for other choices:
A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed.
B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain.
C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?
- A. Maintenance of blood glucose levels between 180 and 200mg/dl
- B. Smoking reduction but not complete cessation
- C. An eye examination every 2 years until age 50
- D. Exercise and a weight reduction diet
Correct Answer: D
Rationale: The correct answer is D, as exercise and a weight reduction diet are essential components in managing type 2 diabetes. Exercise helps lower blood glucose levels and improves insulin sensitivity. Weight reduction reduces insulin resistance. Choice A is incorrect because maintaining blood glucose levels between 180-200mg/dl is too high and can lead to complications. Choice B is incorrect as complete smoking cessation is crucial for overall health and diabetes management. Choice C is incorrect because eye examinations should be done annually, not every 2 years, to monitor for diabetic retinopathy. In summary, choice D is the best option as it directly addresses the management of type 2 diabetes.