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As the nurse provides care for the client newly diagnosed with a large goiter, which interventions should be implemented? Select all that apply.
- A. Observe the client's respiratory status
- B. Elevate the head of the client's bed
- C. Provide a diet high in food used.
- D. Obtain an order for a soft diet
- E. Assess for high fever
- F. Administer prescribed antibiotics
Correct Answer: A,B,D
Rationale: A large goiter can compress the trachea, necessitating respiratory monitoring, head elevation, and a soft diet to ease swallowing.
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The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which priority intervention should be implemented by the nurse?
- A. Start an IV with D5W.
- B. Notify the health-care provider.
- C. Perform a bedside glucose check.
- D. Give the client some orange juice.
Correct Answer: C
Rationale: Weakness, shakiness, and sweating suggest hypoglycemia from an insulinoma; a glucose check confirms this, guiding treatment. IV D5W, HCP notification, and juice follow confirmation.
The nurse is teaching the client diagnosed with type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?
- A. A submarine sandwich, potato chips, and diet cola.
- B. Four (4) slices of a supreme thin-crust pizza and milk.
- C. Smoked turkey sandwich, celery sticks, and unsweetened tea.
- D. A roast beef sandwich, fried onion rings, and a cola.
Correct Answer: C
Rationale: A turkey sandwich, celery, and unsweetened tea are low-carb, low-fat, and diabetes-friendly. Other options are high in carbs or fats, worsening glycemic control.
The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement?
- A. Assess for dehydration and monitor blood glucose levels.
- B. Assess for nausea and vomiting and weigh daily.
- C. Monitor potassium levels and encourage fluid intake.
- D. Administer vasopressin IV and conduct a fluid deprivation test.
Correct Answer: B
Rationale: Nausea/vomiting and daily weights monitor SIADH complications (e.g., hyponatremia, fluid overload). Dehydration is unlikely, potassium is less critical, and vasopressin worsens SIADH.
Which statement by the client about foot care indicates a need for further teaching?
- A. I need to inspect my feet daily.
- B. I should soak my feet each day.
- C. I need to wear shoes whenever I'm not sleeping.
- D. I need to schedule regular appointments with the podiatrist.
Correct Answer: B
Rationale: Soaking feet can lead to skin breakdown in diabetic clients; feet should be washed and dried carefully.
The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client?
- A. Refer the client to the American Diabetes Association.
- B. Do not take any over-the-counter (OTC) medications.
- C. Take the prescribed insulin even when unable to eat because of illness.
- D. Explain the need to get the annual flu and pneumonia vaccines.
Correct Answer: C
Rationale: Continuing insulin during illness prevents DKA by maintaining glucose control. ADA referral, avoiding OTC meds, and vaccines are secondary.