Nokea
Nurse Troy is aware that the most appropriate nursing diagnosis for a client with Addison's disease is:
- A. Risk for infection
- B. Excessive fluid volume
- C. Urinary retention
- D. Hypothermia
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for a client with Addison's disease is 'Risk for infection.' Addison's disease is characterized by corticosteroid deficiency, which leads to immune suppression, making these clients more susceptible to infections. This diagnosis reflects the increased vulnerability of clients with Addison's disease to infections. Choices B, C, and D are incorrect because Addison's disease does not typically present with excessive fluid volume, urinary retention, or hypothermia as primary concerns.
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A client with type 2 diabetes mellitus is being educated on foot care. Which of the following instructions should the nurse provide?
- A. Soak your feet in warm water daily.
- B. Avoid going barefoot to protect your feet.
- C. Inspect your feet daily for any cuts or sores.
- D. Avoid using a heating pad to warm your feet if they are cold.
Correct Answer: C
Rationale: The correct instruction for a client with type 2 diabetes mellitus regarding foot care is to inspect their feet daily for any cuts or sores. This practice helps in early detection of potential issues like cuts, sores, or infections, which can be challenging to heal due to poor circulation in diabetes. Choice A is incorrect because soaking feet in hot water can lead to burns or skin damage, especially for individuals with diabetes who may have reduced sensation. Choice B is incorrect because going barefoot increases the risk of injuries and infections for individuals with diabetes. Choice D is incorrect because using a heating pad can also impair sensation, increasing the risk of burns or injuries for diabetic individuals.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select one that does not apply.
- A. Place the solution on an IV pump at the prescribed rate.
- B. Monitor blood glucose every twelve (12) hours.
- C. Weigh the client weekly, first thing in the morning.
- D. Change the IV tubing every three (3) days.
Correct Answer: D
Rationale: Precautions for clients receiving TPN include placing the solution on an IV pump to control the rate, monitoring blood glucose levels to detect hyperglycemia, and monitoring intake and output to assess fluid balance. Changing the IV tubing every three days is not a standard precaution for clients receiving TPN via a subclavian line.
A client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with exercise. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise?
- A. The best time for me to exercise is every afternoon.
- B. The best time for me to exercise is right after I eat.
- C. The best time for me to exercise is after breakfast.
- D. The best time for me to exercise is after my morning snack.
Correct Answer: A
Rationale: Exercising in the afternoon may coincide with the peak action of NPH insulin, increasing the risk of hypoglycemia. The peak action of NPH insulin typically occurs 4-12 hours after administration, so exercising during this time can further lower blood sugar levels. Choices B, C, and D are better options as they suggest exercising at times that are less likely to overlap with the peak insulin action, reducing the risk of hypoglycemia.
A client with DM is experiencing symptoms of hypoglycemia. Which action should the nurse take first?
- A. Give the client a glass of orange juice.
- B. Administer insulin as ordered.
- C. Check the client's blood glucose level.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: The correct first action when a client with DM is experiencing symptoms of hypoglycemia is to check the client's blood glucose level. This step is crucial to confirm hypoglycemia before initiating any treatment. Giving the client orange juice (Choice A) is a common intervention for treating hypoglycemia, but it should not be done before confirming the blood glucose level. Administering insulin (Choice B) is not appropriate for hypoglycemia as it would further decrease the blood glucose levels. Notifying the healthcare provider (Choice D) can be important, but the immediate priority is to assess the blood glucose level to guide treatment.
For the first 72 hours after thyroidectomy surgery, nurse Jamie would assess the female client for Chvostek's sign and Trousseau's sign because they indicate which of the following?
- A. Hypocalcemia
- B. Hypercalcemia
- C. Hypokalemia
- D. Hyperkalemia
Correct Answer: A
Rationale: Chvostek's and Trousseau's signs are clinical manifestations that suggest hypocalcemia, a common complication following thyroidectomy. Chvostek's sign is elicited by tapping the facial nerve, resulting in facial muscle contraction, while Trousseau's sign is provoked by inflating a blood pressure cuff, leading to carpal spasm. Both signs are indicative of low calcium levels in the blood. Therefore, options B, C, and D are incorrect as they do not correlate with the signs specifically associated with hypocalcemia.