Nokea
A client admitted for regulation of her insulin dosage. The client takes 15 units of Humulin N insulin at 8 AM every day.
At 4 PM, which of the following nursing observations would indicate a complication from the insulin?
- A. Acetone odor to the breath, polyuria, and flushed skin.
- B. Irritability, tachycardia, and diaphoresis.
- C. Headache, nervousness, and polydipsia.
- D. Tenseness, tachycardia, and anorexia.
Correct Answer: B
Rationale: Strategy: Determine the cause of each symptom and how it relates to hypoglycemia. (1) signs of hyperglycemia (2) correct-Humulin N insulin is an intermediate-acting insulin that peaks from eight to twelve hours after administration; this is when signs and symptoms of hypoglycemia will occur (3) signs of hyperglycemia (4) signs of hyperglycemia
You may also like to solve these questions
The nurse is caring for a client with a history of systemic lupus erythematosus.
- A. Which symptom is expected in a client with systemic lupus erythematosus?
- B. Chest pain and shortness of breath.
- C. Fever and joint pain.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Fever and joint pain are common in systemic lupus erythematosus due to autoimmune inflammation. Chest pain may occur with pericarditis, but weight gain and headaches are less specific.
The nurse is caring for clients in outpatient surgery.
- A. What is the best statement by the nurse to the mother of a four-year-old preparing for eye surgery?
- B. Draw a picture of the eye to explain what will happen.'
- C. Tell your daughter that the procedure will take one hour.'
- D. Use dolls or puppets to explain how to get ready for surgery.'
- E. Read an age-appropriate illustrated book about eye surgery to your daughter.'
Correct Answer: C
Rationale: For a four-year-old, using dolls or puppets to demonstrate the procedure in simple terms is developmentally appropriate, addressing what the child will experience (see, hear, feel). Drawing pictures or reading books is better for school-aged children, and time concepts like one hour are not relatable to preschoolers.
A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.
A 66-year-old woman is being evaluated for pernicious anemia. Which assessment findings would be most apt to be present in a client with pernicious anemia?
- A. Easy bruising
- B. Pain in the legs
- C. Fine red rash on the extremities
- D. Pruritus
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes neurological symptoms like leg pain or paresthesia. Bruising, rashes, or pruritus are less specific to this condition.
The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.