Nokea
Before the client is discharged, the physician orders lypressin (Diapid) to be administered p.r.n. When instructing the client about how to take this drug at home, the nurse tells the client to administer the drug when experiencing which sign or symptom?
- A. Increased thirst
- B. Onset of a headache
- C. Dark yellow urine
- D. A runny nose
Correct Answer: A
Rationale: Increased thirst is a symptom of diabetes insipidus indicating the need for lypressin to control fluid loss.
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The nurse is providing teaching to multiple clients. Which client should the nurse determine would benefit if the following illustration were utilized when teaching?
- A. The client with hyperthyroidism
- B. The client with diabetes mellitus
- C. The client with Addison's disease
- D. The client with Cushing's syndrome
Correct Answer: D
Rationale: Clinical manifestations of Cushing's syndrome, such as moon face and fat pads, match the illustration.
A client is admitted to the hospital with recently diagnosed Type I diabetes mellitus and is to have fasting blood work drawn this morning. At 7:00 A.M., the lab has not arrived to draw the blood. The client's dose of regular insulin is scheduled for 7:30 A.M. What is the best action for the nurse to take?
- A. Give the insulin as ordered
- B. Withhold the insulin until the lab comes and the client will be eating within 15 to 30 minutes
- C. Withhold the insulin until the blood has been drawn and the client has eaten
- D. Do not administer insulin until the blood work has been drawn and the results have been called back to the unit
Correct Answer: C
Rationale: Withholding insulin until blood is drawn and the client has eaten prevents hypoglycemia during fasting blood work.
The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included?
- A. Administer steroid medications.
- B. Place the client on fluid restriction.
- C. Provide frequent stimulation.
- D. Consult physical therapy for gait training.
Correct Answer: A
Rationale: Steroid replacement (e.g., hydrocortisone) is essential for Addison’s to replace deficient cortisol/aldosterone. Fluid restriction, stimulation, and gait training are inappropriate.
The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client?
- A. Diabetes insipidus (DI).
- B. Crohn's disease.
- C. Narcotic addiction.
- D. Peritonitis.
Correct Answer: C
Rationale: Chronic pancreatitis often requires long-term pain management, risking narcotic addiction. DI, Crohn’s, and peritonitis are unrelated complications.
The nurse is caring for the client with SIADH. Which interventions should the nurse plan to implement? Select all that apply.
- A. Obtain the weight near the same time each morning.
- B. Place the client on a fluid-restricted diet as prescribed.
- C. Prepare to give a 500-mL NaCl intravenous fluid bolus.
- D. Administer furosemide intravenously as prescribed.
- E. Monitor for hyperactive reflexes and heightened alertness.
Correct Answer: A,B,D
Rationale: Daily weights monitor fluid retention, fluid restriction treats hyponatremia, and furosemide addresses fluid overload in SIADH.