Nokea
An elderly woman has been recently diagnosed as having Type 2 diabetes. Which of the following complaints that she has is most likely to be related to the diagnosis of diabetes mellitus?
- A. Pruritus vulvae
- B. Cough
- C. Eructation
- D. Singultus
Correct Answer: A
Rationale: Pruritus vulvae is common in diabetes due to yeast infections from elevated glucose levels.
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The nurse is assessing a client in an outpatient clinic. Which assessment data are a risk factor for developing pheochromocytoma?
- A. A history of skin cancer.
- B. A history of high blood pressure.
- C. A family history of adrenal tumors.
- D. A family history of migraine headaches.
Correct Answer: C
Rationale: A family history of adrenal tumors increases pheochromocytoma risk, as it’s a catecholamine-secreting adrenal tumor. Skin cancer, hypertension, and migraines are unrelated.
The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication?
- A. When is the last time you took your insulin?
- B. When did you have your last meal?
- C. Have you had some type of infection lately?
- D. How long have you had diabetes?
Correct Answer: C
Rationale: Infections are a common trigger for HHNS, precipitating hyperglycemia. Insulin timing, meal timing, and diabetes duration are less directly causative.
Which nursing assessment is most helpful in evaluating the status of a client with Addison's disease?
- A. Blood pressure
- B. Bowel sounds
- C. Breath sounds
- D. Heart sounds
Correct Answer: A
Rationale: Hypotension is a key sign of Addison's disease due to decreased aldosterone and cortisol.
The client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). Which assessment data indicate the medication has been effective?
- A. The client has a three (3)-pound weight gain.
- B. The client has a decreased pulse rate.
- C. The client's temperature is WNL.
- D. The client denies any diaphoresis.
Correct Answer: C
Rationale: Normal temperature indicates corrected hypothermia from hypothyroidism. Weight gain, decreased pulse, and no diaphoresis are not specific indicators.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which intervention should the nurse delegate to the UAP?
- A. Assist the client with abdominal pain to turn to the side and flex the knees.
- B. Monitor the Jackson Pratt drainage tube to ensure it is draining properly.
- C. Check to see if the client is sleeping after pain medication is administered.
- D. Empty the bedside commode of the client who has been having melena.
Correct Answer: A
Rationale: Assisting with positioning is within the UAP’s scope and promotes comfort. Monitoring drains, assessing sleep, and handling melena require RN skills.