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A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?
- A. Potassium level of 4.0 mEq/L.
- B. Blood glucose level of 180 mg/dL.
- C. Urine output of 50 mL/hour.
- D. Absence of ketones in the urine.
Correct Answer: D
Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.
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A client with hypothyroidism is prescribed levothyroxine. What symptom indicates that the dosage may need adjustment?
- A. Increased appetite and weight gain.
- B. Increased sensitivity to cold and dry skin.
- C. Increased heart palpitations and sweating.
- D. Increased shortness of breath and rapid heart rate.
Correct Answer: B
Rationale: Increased sensitivity to cold and dry skin may indicate that the dosage of levothyroxine is too low, requiring adjustment. This symptom is typical of hypothyroidism when the body's metabolism slows down, leading to feeling cold and having dry skin. Choices A, C, and D present symptoms more commonly associated with hyperthyroidism, where the body is in a state of overactivity, leading to weight loss, increased heart rate, and sweating. Therefore, these symptoms would not indicate the need for dosage adjustment in a client with hypothyroidism.
A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?
- A. Auscultate breath sounds.
- B. Measure vital signs.
- C. Palpate the abdomen.
- D. Observe the skin for bruising.
Correct Answer: C
Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.
A client with a history of alcohol abuse presents with confusion and unsteady gait. The nurse suspects Wernicke's encephalopathy. Which treatment should the nurse anticipate?
- A. Thiamine supplementation
- B. Folic acid replacement
- C. Intravenous glucose
- D. Magnesium sulfate administration
Correct Answer: A
Rationale: Wernicke's encephalopathy is a neurological condition commonly caused by a deficiency in thiamine, often seen in clients with chronic alcohol abuse. Thiamine supplementation is the primary treatment to prevent further neurological damage. Folic acid replacement (choice B) is not the correct treatment for Wernicke's encephalopathy. Intravenous glucose (choice C) may be necessary in some cases of Wernicke's encephalopathy, but thiamine supplementation takes precedence. Magnesium sulfate administration (choice D) is not indicated as the primary treatment for Wernicke's encephalopathy.
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?
- A. Had a cold and ear infection for the past two days
- B. Missed a dose of insulin
- C. Did not follow dietary restrictions
- D. Overexerted during exercise
Correct Answer: A
Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
- A. We will call the health care provider if the child develops acne.
- B. Our child should brush and floss carefully after every meal.
- C. We will skip the next dose if vomiting or fever occur.
- D. When our child is seizure-free for 6 months, we can stop the medication.
Correct Answer: B
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.