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The agitated client is hospitalized with tachycardia, dyspnea, and intermittent chest palpitations. The client's BP is 170/110 mm Hg, and HR is 130 bpm. The client's health history reveals thinning hair, recent 10-lb weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth, moist skin. Which prescribed intervention should be the nurse's priority?
- A. 12-lead electrocardiogram (ECG) and cardiac enzyme levels.
- B. Obtain thyroid-stimulating hormone (TSH) and free T4 levels.
- C. Propranolol 2 mg IV q15 min or until symptoms are controlled.
- D. Propylthiouracil 600-mg oral loading dose; then 200 mg orally q4h.
Correct Answer: C
Rationale: Propranolol provides rapid symptomatic relief of thyrotoxicosis by controlling cardiac and psychomotor manifestations.
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The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse?
- A. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation.
- B. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22.
- C. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28.
- D. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.
Correct Answer: C
Rationale: Addison’s with hypotension (80/45), tachycardia (124), and lethargy suggests adrenal crisis, requiring an experienced nurse. Ventilator care, stable Cushing’s, and post-thyroidectomy are less acute.
The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication?
- A. When is the last time you took your insulin?
- B. When did you have your last meal?
- C. Have you had some type of infection lately?
- D. How long have you had diabetes?
Correct Answer: C
Rationale: Infections are a common trigger for HHNS, precipitating hyperglycemia. Insulin timing, meal timing, and diabetes duration are less directly causative.
The nursing assistant reports to the nurse that the client's blood glucose reading is 58 mg/dL. What is the most appropriate nursing action at this time?
- A. The nurse is the need to be a condition.
- B. Give the client 1/4 cup of sweet fruit juice.
- C. Report the client's symptoms to the physician.
- D. Perform a complete head-to-toe assessment.
Correct Answer: B
Rationale: A blood glucose of 58 mg/dL with symptoms indicates hypoglycemia, requiring immediate administration of a fast-acting carbohydrate like fruit juice.
The nurse is caring for the client with type 2 DM. Which instructions should the nurse provide to the client regarding diabetes management during stress or illness? Select all that apply.
- A. Notify the health care provider if unable to keep fluids or foods down.
- B. Test fingerstick glucose levels and urine ketones daily and keep a record.
- C. Continue to take oral hypoglycemic medications and/or insulin as prescribed.
- D. Supplement food intake with carbohydrate-containing fluids, such as juices or soups.
- E. When on an oral agent, administer insulin in addition to the oral agent during the illness.
- F. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs.
Correct Answer: A,C
Rationale: Notifying the HCP prevents dehydration, and continuing medications manages hyperglycemia during illness.
The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test?
- A. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours.
- B. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours.
- C. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test.
- D. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.
Correct Answer: C
Rationale: The fluid deprivation test involves NPO status with hourly vitals and weights to assess urine concentration, diagnosing DI. Other options describe incorrect procedures.