Nokea
The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care?
- A. Infuse 0.9% normal saline intravenously.
- B. Administer intermediate-acting insulin.
- C. Perform blood glucometer checks daily.
- D. Monitor arterial blood gas (ABG) results.
Correct Answer: A
Rationale: IV normal saline corrects severe dehydration in HHNS, a priority collaborative intervention. Insulin is secondary, daily glucose checks are insufficient, and ABGs are less critical in HHNS.
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The nurse is reviewing information for the client with type 1 DM. The nurse concludes that the client may be experiencing the Somogyi phenomenon, as evidenced by which finding?
- A. 02:00 blood glucose between 80-110 mg/dL and morning levels between 80-100 mg/dL
- B. 02:00 blood glucose between 50-60 mg/dL and morning levels between 48-62 mg/dL
- C. 02:00 blood glucose between 130-140 mg/dL and morning levels between 180-200 mg/dL
- D. 02:00 blood glucose between 45-62 mg/dL and morning levels between 200-305 mg/dL
Correct Answer: D
Rationale: The nurse should conclude that the low blood glucose in the middle of the night (45-62 mg/dL) and a rebound morning hyperglycemia (200-305 mg/dL) are signs of Somogyi phenomenon, also known as Somogyi effect.
The nurse identified a concept of metabolism for a client diagnosed with diabetes. Which antecedent would be identified as placing the client at risk for diabetes?
- A. Nutrition.
- B. Sensory perception.
- C. pH regulation.
- D. Medication.
Correct Answer: A
Rationale: Poor nutrition (e.g., high sugar intake) is a key risk factor for diabetes, impacting metabolism. Sensory, pH, and medications are less directly causative.
The client diagnosed with acute pancreatitis has a ruptured pseudocyst. Which procedure should the nurse anticipate the HCP prescribing?
- A. Paracentesis.
- B. Chest tube insertion.
- C. Lumbar puncture.
- D. Biopsy of the pancreas.
Correct Answer: A
Rationale: A ruptured pancreatic pseudocyst can cause peritoneal irritation or fluid accumulation, potentially requiring drainage. Paracentesis removes abdominal fluid, which may be performed in severe cases, though surgical drainage or endoscopic intervention is more specific. Chest tube insertion is for pleural issues, lumbar puncture is for cerebrospinal fluid, and pancreatic biopsy is diagnostic, not therapeutic for a ruptured pseudocyst.
The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care?
- A. Diarrhea due to gastrointestinal (GI) hypermotility
- B. Imbalanced nutrition due to insufficient calorie intake
- C. Activity intolerance due to increased metabolic rate
- D. Anxiety due to forgetfulness and slowed speech
Correct Answer: D
Rationale: Forgetfulness and slowed speech that occur with hypothyroidism can cause the client to be anxious.
A client who has just had a thyroidectomy returns to the unit in stable condition. What equipment is it essential for the nurse to have readily available?
- A. Tracheostomy set
- B. Thoracotomy tray
- C. Dressing set
- D. Ice collar
Correct Answer: A
Rationale: A tracheostomy set is essential post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma.