Nokea
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?
- A. Type 1 diabetes.
- B. Type 2 diabetes.
- C. Gestational diabetes.
- D. Acanthosis nigricans.
Correct Answer: B
Rationale: Obesity (BMI ~44) and a nonhealing wound suggest type 2 diabetes, associated with insulin resistance. Type 1 is less likely, gestational diabetes requires pregnancy, and acanthosis nigricans is a symptom, not a disease.
You may also like to solve these questions
When the client asks why a diabetic relative cannot take insulin orally, what is the best answer?
- A. Insulin is inactivated by digestive enzymes.
- B. Insulin is absorbed too quickly in the stomach.
- C. Insulin is irritating to the gastric mucosa.
- D. Insulin is incompatible with many foods.
Correct Answer: A
Rationale: Insulin is a protein that is broken down by digestive enzymes, rendering it ineffective if taken orally.
Which documentation finding provides the best indication that the client has successfully avoided an adrenal (addisonian) crisis after surgery?
- A. The client's pedal edema has lessened.
- B. Capillary blood glucose level is within normal limits.
- C. Vital signs are within preoperative ranges.
Correct Answer: C
Rationale: Stable vital signs indicate the absence of adrenal crisis, characterized by hypotension and shock.
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism?
- A. Increase the amount of fiber in the diet.
- B. Encourage a low-calorie, low-protein diet.
- C. Decrease the client's fluid intake to 1,000 mL/day.
- D. Provide six (6) small, well-balanced meals a day.
Correct Answer: D
Rationale: Six small, balanced meals meet the increased metabolic demands of hyperthyroidism. Fiber, low-calorie diets, and fluid restriction are inappropriate.
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?
- A. Serum sodium of 112 mEq/L and a headache.
- B. Serum potassium of 5.0 mEq/L and a heightened awareness.
- C. Serum calcium of 10 mg/dL and tented tissue turgor.
- D. Serum magnesium of 1.2 mg/dL and large urinary output.
Correct Answer: A
Rationale: Severe hyponatremia (112 mEq/L) and headache in SIADH risk seizures, requiring immediate HCP notification. Other findings are less critical or unrelated.
The nurse administers 15 units of glargine insulin at 2100 hours to the client when the client's fingerstick blood glucose reading is 110 mg/dL. At 2300, an NA reports that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate?
- A. You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime.'
- B. It is not necessary for this client to have a snack; glargine insulin is absorbed over 24 hours and doesn't have a peak.'
- C. The next time the client wakes up, check a blood glucose level and then give a 15-gram carbohydrate snack.'
- D. I will notify the HCP; a snack at this time will affect the next blood glucose level and dose of glargine insulin.'
Correct Answer: B
Rationale: The onset of glargine is 1 hour; it has no peak action, and it lasts for 24 hours. Because it has no peak action, a bedtime snack is unnecessary.