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The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement?
- A. Increase the regular insulin IV drip.
- B. Check the client's urine for ketones.
- C. Provide the client with a therapeutic diabetic meal.
- D. Notify the HCP to obtain an order to decrease insulin.
Correct Answer: D
Rationale: A glucose drop from 780 to 300 mg/dL requires HCP notification to adjust insulin, preventing hypoglycemia. Increasing insulin, checking ketones, or meals are inappropriate.
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An 18-year-old female client, 5'4 tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed?
- A. Type 1 diabetes.
- B. Type 2 diabetes.
- C. Gestational diabetes.
- D. Acanthosis nigricans.
Correct Answer: B
Rationale: Obesity (BMI ~44) and a nonhealing wound suggest type 2 diabetes, associated with insulin resistance. Type 1 is less likely, gestational diabetes requires pregnancy, and acanthosis nigricans is a symptom, not a disease.
A clinic nurse is teaching the client newly diagnosed with hypothyroidism. Which instructions should the nurse provide about taking levothyroxine sodium? Select all that apply.
- A. Take the medication 1 hour before or 2 hours after breakfast.
- B. Call the clinic if the pulse before taking the medication is greater than 100 beats per minute.
- C. Report adverse drug effects, including weight gain, cold intolerance, and alopecia.
- D. Take this drug as prescribed; it replaces thyroid hormone thatå‚¾å‘ diminished or absent.
- E. Have frequent laboratory monitoring to be sure your levels of T3 and T4 decrease.
Correct Answer: A,B,D
Rationale: Taking levothyroxine on an empty stomach ensures absorption, notifying the clinic for tachycardia prevents overdose, and taking it as prescribed replaces deficient hormone.
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.
Which statement by the client about foot care indicates a need for further teaching?
- A. I need to inspect my feet daily.
- B. I should soak my feet each day.
- C. I need to wear shoes whenever I'm not sleeping.
- D. I need to schedule regular appointments with the podiatrist.
Correct Answer: B
Rationale: Soaking feet can lead to skin breakdown in diabetic clients; feet should be washed and dried carefully.
The nurse is teaching the client newly diagnosed with type 2 DM. Which information should the nurse emphasize in the session?
- A. Use the arm when self-administering insulin.
- B. Exercise for 30 minutes daily, preferably after a meal.
- C. Consume 30% of the daily calorie intake from protein foods.
- D. Eat a 30-gram carbohydrate snack prior to strenuous activity.
Correct Answer: B
Rationale: Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise contributes to weight loss, which also decreases insulin resistance.