Nokea
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.
You may also like to solve these questions
The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting 'funny.' Which intervention should the nurse implement first?
- A. Instruct the UAP to obtain the blood glucose level.
- B. Have the client drink eight (8) ounces of orange juice.
- C. Go to the client's room and assess the client for hypoglycemia.
- D. Prepare to administer one (1) ampule 50% dextrose intravenously.
Correct Answer: C
Rationale: Assessing for hypoglycemia (e.g., confusion, headache) confirms the cause, as Humulin R peaks around 3 hours. UAPs cannot check glucose, and treatment follows confirmation.
The nurse's next door neighbor calls. He says he cannot awaken his 21-year-old wife. The nurse notes that the client is unconscious and is having deep respirations. Her breath has a fruity smell to it. The husband says that his wife has been eating and drinking a lot recently and that last night she vomited before lying down. What is the most appropriate action for the nurse to take?
- A. Start cardiopulmonary resuscitation
- B. Get her to a hospital immediately
- C. Try to rouse her by giving her coffee
- D. Give her sweetened orange juice
Correct Answer: B
Rationale: Fruity breath, unconsciousness, and symptoms of polyphagia, polydipsia, and vomiting suggest diabetic ketoacidosis, requiring immediate hospital care.
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
- A. Glucose.
- B. Potassium.
- C. Calcium.
- D. Sodium.
Correct Answer: B
Rationale: DKA causes potassium depletion due to acidosis and diuresis; replacement is anticipated to prevent arrhythmias. Glucose is not an electrolyte, and calcium/sodium are less critical.
A woman with hypothyroidism asks the nurse why the doctor told her she cannot have a sedative. The nurse's response is based on which of the following facts?
- A. Sedatives potentiate thyroid replacement medication.
- B. Clients with hypothyroidism have increased susceptibility to all sedative drugs.
- C. Sedatives will have a paradoxical effect on clients with hypothyroidism.
- D. Sedatives would cause fluid retention and hypernatremia.
Correct Answer: B
Rationale: Hypothyroidism increases sensitivity to sedatives, risking excessive sedation or respiratory depression.
The nurse is preparing to care for four clients. In which order should the nurse plan to attend to the clients?
- A. Client following a thyroidectomy who has hoarseness and an SaO2 of 86%
- B. Client with hyperparathyroidism with a serum calcium level of 10.1 mg/dL
- C. Client with diabetes insipidus drinking frequently and asking for more cold water
- D. Client with hyperthyroidism who has a temperature of 102.2°F (39°C) and tachycardia
Correct Answer: A,D,C,B
Rationale: The thyroidectomy client with low SaO2 has a life-threatening airway issue, followed by the hyperthyroidism client at risk for thyroid storm, the DI client at risk for dehydration, and the stable hyperparathyroidism client last.