Nokea
At 10 A.M., a client with Type 1 diabetes becomes very irritable and starts to yell at the nurse. Which initial nursing assessment should take priority?
- A. Blood pressure and pulse
- B. Color and temperature of skin
- C. Reflexes and muscle tone
- D. Serum electrolytes and glucose
Correct Answer: D
Rationale: Irritability in Type 1 diabetes suggests hypoglycemia or hyperglycemia, requiring priority assessment of serum glucose.
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The client with type 2 DM is scheduled for cardiac rehabilitation exercises (cardiac rehab). The nurse notes that the client's blood glucose level is 300 mg/dL and that the urine is positive for ketones. How should the nurse proceed?
- A. Send the client to cardiac rehab; exercise will lower the client's glucose level.
- B. Give insulin; send the client for exercises with a 15-gram carbohydrate snack.
- C. Delay cardiac rehab; blood glucose levels will decrease too much with exercise.
- D. Cancel cardiac rehab; blood glucose levels will increase further with exercise.
Correct Answer: D
Rationale: Exercising with blood glucose levels exceeding 250 mg/dL and ketonuria increases the secretion of glucagon, growth hormone, and catecholamines, causing the liver to release more glucose.
Twelve hours after a transsphenoidal hypophysectomy, the client keeps clearing his throat and complains of a drip in his mouth. To accurately assess this, the nurse should test the fluid for:
- A. sugar.
- B. protein.
- C. bacteria.
- D. blood.
Correct Answer: A
Rationale: A post-nasal drip post-transsphenoidal hypophysectomy may indicate cerebrospinal fluid (CSF) leakage, which contains glucose (sugar), unlike saliva or mucus.
The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care?
- A. Diarrhea due to gastrointestinal (GI) hypermotility
- B. Imbalanced nutrition due to insufficient calorie intake
- C. Activity intolerance due to increased metabolic rate
- D. Anxiety due to forgetfulness and slowed speech
Correct Answer: D
Rationale: Forgetfulness and slowed speech that occur with hypothyroidism can cause the client to be anxious.
The nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 am to the client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct?
- A. The onset of the regular insulin will be at 7:45 am and the peak at 1:00 pm.
- B. The onset of the regular insulin will be at 8:00 am and the peak at 10:00 am.
- C. The onset of the NPH insulin will be at 8:00 am and the peak at 10:00 am.
- D. The onset of the NPH insulin will be at 12:30 pm and the peak at 11:30 pm.
Correct Answer: B
Rationale: The onset of regular insulin (short acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours.
Which assessment findings would the nurse expect to document the patient's health care, and the patient's health care? Select all that apply.
- A. The client is hypertensive and tachycardic.
- B. The client is dyspneic and hypotensive.
- C. The client breathes noisily and smells of acetone.
- D. The client stares blankly and smells of alcohol.
- E. The client has warm, flushed skin and has vomited.
- F. The client complains of abdominal pain and is thirsty.
Correct Answer: C,E,F
Rationale: DKA is characterized by acetone breath, warm/flushed skin, vomiting, abdominal pain, and thirst due to hyperglycemia and dehydration.