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The nurse assesses that the client diagnosed with Cushing's syndrome has an irregular HR, right arm ecchymosis, 4+ pitting edema in the legs, and a blood glucose of 140 mg/dL. Which action should be the nurse's priority?
- A. Weigh the client again
- B. Administer insulin as prescribed
- C. Notify the health care provider
- D. Measure the client's abdominal girth
Correct Answer: C
Rationale: The HCP should be notified immediately to address the irregular HR, which may result from hypokalemia, a common issue in Cushing's syndrome.
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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.
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus?
- A. Serum sodium.
- B. Serum calcium.
- C. Urine glucose.
- D. Urine white blood cells.
Correct Answer: A
Rationale: Diabetes insipidus causes dilute urine, risking hypernatremia; serum sodium monitoring is critical. Calcium, urine glucose, and WBCs are unrelated.
Which monitoring approach is best for the nurse to recommend?
- A. Using the urine with a chemical reagent strip
- B. Using a glucometer to check capillary blood glucose levels
- C. Having laboratory personnel draw venous blood samples
- D. Arranging for testing by a home health agency nurse
Correct Answer: B
Rationale: A glucometer provides accurate, real-time blood glucose levels for effective diabetes management.
A woman with a tumor of the adrenal cortex says to the nurse, 'Will I always look this ugly? I hate having a beard.' What is the best response for the nurse to make?
- A. After surgery, you will not develop any more symptoms, but the changes you have now will linger.'
- B. That varies from person to person. You should ask your physician.'
- C. After surgery, your appearance should gradually return to normal.'
- D. Electrolysis and plastic surgery should make your appearance normal.'
Correct Answer: C
Rationale: Post-adrenalectomy, hormonal imbalances causing symptoms like hirsutism should resolve, gradually normalizing appearance.
Which nursing diagnosis should the nursing team consider when developing this client's care plan?
- A. Activity intolerance
- B. Self-care deficit
- C. Ineffective breathing
- D. Impaired swallowing
Correct Answer: B
Rationale: Acromegaly can cause joint pain and muscle weakness, contributing to self-care deficits.