Nokea
The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit?
- A. Kussmaul's respirations.
- B. Diarrhea and epigastric pain.
- C. Dry mucous membranes.
- D. Ketone breath odor.
Correct Answer: C
Rationale: HHNS causes severe dehydration, leading to dry mucous membranes. Kussmaul’s respirations and ketone odor are DKA-specific, and diarrhea/pain are less common.
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An adolescent with IDDM is learning about a diabetic diet. He asks the nurse if he will ever be able to go out to eat with his friends again. What is the most appropriate answer for the nurse to give?
- A. You can go out with them, but you should take your own snack with you.'
- B. Yes. You will learn what foods are allowed so you can eat with your friends.'
- C. When you get food out in a restaurant, be sure to order diet soft drinks.'
- D. Eating out will not be possible on a diabetic diet. Why don't you plan to invite your friends to your house?'
Correct Answer: B
Rationale: Learning appropriate food choices allows the adolescent to eat out safely, promoting social integration and adherence to the diabetic diet.
The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention?
- A. Administer the insulin that is due now.
- B. Call the lab for a STAT serum glucose level.
- C. Have the client choose foods for a meal now.
- D. Provide juice with 15 grams of carbohydrates.
Correct Answer: D
Rationale: Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.
Which nursing intervention is essential for monitoring the client's condition?
- A. Measuring intake and output
- B. Muxying blood glucose levels
- C. Inserting a Foley catheter
- D. Sending urine samples to the laboratory
Correct Answer: A
Rationale: Monitoring intake and output is critical in diabetes insipidus to assess fluid balance and the severity of polyuria.
Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information?
- A. Antibiotics will help to prevent respiratory complications following surgery.
- B. Meningitis is a complication following transsphenoidal hypophysectomy.
- C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
- D. Hormone replacement is essential after hypophysectomy.
Correct Answer: B
Rationale: The transsphenoidal approach through the mouth increases the risk of meningitis due to oral bacteria, necessitating prophylactic antibiotics.
The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis?
- A. The client has an autoimmune problem causing the destruction of the adrenal cortex.
- B. The client has been taking steroid medications for an extended period for another disease process.
- C. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol.
- D. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.
Correct Answer: B
Rationale: Iatrogenic Cushing’s results from prolonged exogenous steroid use, mimicking endogenous hypercortisolism. Autoimmune issues, pituitary tumors, and idiopathic causes are incorrect.