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A client with DM is experiencing symptoms of hypoglycemia. Which action should the nurse take first?
- A. Give the client a glass of orange juice.
- B. Administer insulin as ordered.
- C. Check the client's blood glucose level.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: The correct first action when a client with DM is experiencing symptoms of hypoglycemia is to check the client's blood glucose level. This step is crucial to confirm hypoglycemia before initiating any treatment. Giving the client orange juice (Choice A) is a common intervention for treating hypoglycemia, but it should not be done before confirming the blood glucose level. Administering insulin (Choice B) is not appropriate for hypoglycemia as it would further decrease the blood glucose levels. Notifying the healthcare provider (Choice D) can be important, but the immediate priority is to assess the blood glucose level to guide treatment.
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A nurse manager works hard to keep employee morale high with the thought that this will lead to effective employees doing the best work they can. Which of the following theories does this best describe?
- A. Theory X
- B. Theory Y
- C. Servant leadership
- D. Scientific management
Correct Answer: B
Rationale: Theory Y, as proposed by Douglas McGregor, emphasizes that employees are intrinsically motivated and seek responsibility. It suggests that high morale leads to high productivity, aligning with the nurse manager's actions. Theory X, on the other hand, assumes employees are inherently lazy and need to be closely monitored and controlled. Servant leadership focuses on serving others first and prioritizing their needs, which is not directly related to the scenario described. Scientific management, developed by Frederick Taylor, emphasizes efficiency and standardization through systematic study and organizational control, which is not the primary focus of the nurse manager's approach to boosting employee morale.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select one that does not apply.
- A. Place the solution on an IV pump at the prescribed rate.
- B. Monitor blood glucose every twelve (12) hours.
- C. Weigh the client weekly, first thing in the morning.
- D. Change the IV tubing every three (3) days.
Correct Answer: D
Rationale: Precautions for clients receiving TPN include placing the solution on an IV pump to control the rate, monitoring blood glucose levels to detect hyperglycemia, and monitoring intake and output to assess fluid balance. Changing the IV tubing every three days is not a standard precaution for clients receiving TPN via a subclavian line.
The healthcare provider is assessing a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory findings is most consistent with this condition?
- A. Increased serum sodium
- B. Decreased urine specific gravity
- C. Decreased serum osmolality
- D. Increased serum potassium
Correct Answer: C
Rationale: The correct answer is C: Decreased serum osmolality. Syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by the excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. The dilution of sodium results in decreased serum osmolality. Option A is incorrect because SIADH causes hyponatremia, resulting in decreased serum sodium levels. Option B is incorrect because SIADH leads to concentrated urine with increased urine specific gravity. Option D is incorrect as SIADH does not typically affect serum potassium levels.
The nurse is caring for a client with hypothyroidism. Which of the following clinical findings should the nurse expect?
- A. Tachycardia
- B. Weight loss
- C. Cold intolerance
- D. Diaphoresis
Correct Answer: C
Rationale: Cold intolerance is a classic symptom of hypothyroidism. In hypothyroidism, the body's metabolic rate is decreased, leading to a decreased ability to regulate body temperature. This results in a feeling of being cold most of the time. Tachycardia (Choice A) is more commonly associated with hyperthyroidism, not hypothyroidism. Weight loss (Choice B) and diaphoresis (Choice D) are also more characteristic of hyperthyroidism, where there is an increased metabolic rate and excess heat production.
Nurse Troy is aware that the most appropriate nursing diagnosis for a client with Addison's disease is:
- A. Risk for infection
- B. Excessive fluid volume
- C. Urinary retention
- D. Hypothermia
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for a client with Addison's disease is 'Risk for infection.' Addison's disease is characterized by corticosteroid deficiency, which leads to immune suppression, making these clients more susceptible to infections. This diagnosis reflects the increased vulnerability of clients with Addison's disease to infections. Choices B, C, and D are incorrect because Addison's disease does not typically present with excessive fluid volume, urinary retention, or hypothermia as primary concerns.