Nokea
The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
- A. Serum blood glucose level of 74 mg/dL.
- B. Pulse oximeter reading of 90%.
- C. Telemetry reading showing sinus bradycardia.
- D. The client is lethargic and sleeps all the time.
Correct Answer: B
Rationale: A pulse oximetry of 90% indicates hypoxia, requiring immediate intervention in myxedema coma. Normal glucose, bradycardia, and lethargy are expected.
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To prepare for potential postoperative complications related to the thyroidectomy, which item is necessary to keep at the client's bedside?
- A. Dressing change kit
- B. Tracheostomy tray
- C. Ampule of epinephrine
- D. Mechanical ventilator
Correct Answer: B
Rationale: A tracheostomy tray is essential in case of airway obstruction due to swelling or hematoma post-thyroidectomy.
Before administering this medication, what is essential for the nurse to ask the client?
- A. Do you have trouble swallowing?
- B. Do you keep the child form of medication?
- C. Have you had digestive disorders in the past?
- D. Is there a possibility you could be pregnant?
Correct Answer: D
Rationale: Propylthiouracil is contraindicated in pregnancy due to potential teratogenic effects.
The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
- A. Administer 50% dextrose (IVP).
- B. Notify the health-care provider.
- C. Move the client to the ICU.
- D. Check the serum glucose level.
Correct Answer: D
Rationale: Checking glucose confirms hypoglycemia or hyperglycemia as the cause of unconsciousness, guiding treatment. Dextrose, HCP notification, or ICU transfer follow confirmation.
The nurse is interviewing four clients. Which client is at the greatest risk for developing type 2 DM?
- A. 56-year-old Hispanic female
- B. 40-year-old Asian American female
- C. 25-year-old obese Caucasian male
- D. 38-year-old Native American male
Correct Answer: D
Rationale: Research has shown that the highest incidence of DM is among Native Americans.
An adolescent with newly diagnosed Type I diabetes mellitus asks the nurse if he can continue to play football. What is the best answer for the nurse to give?
- A. Now that you have diabetes, you should not play football because you may get a cut that will not heal.'
- B. If you work with your physician to regulate the insulin dosage and your diet, you should be able to play football.'
- C. It would be better for you to work as equipment manager so you will not be under as much stress.'
- D. You can probably continue to play football if you can regulate it so that you have the same amount of exercise each day.'
Correct Answer: B
Rationale: With proper insulin and diet management, the adolescent can safely play football, supporting physical activity and normalcy.