Nokea
The nurse discovers a patient with type I diabetes drowsy and tremulous, the skin is cool and moist, and the respirations are 32 and shallow. The nurse recognizes the patient is having which type of reaction and quickly provides which intervention?
- A. hypoglycemic reaction; give 6 oz of orange juice.
- B. hyperglycemic reaction; give ordered regular insulin.
- C. hyperglycemic hyperosmolar nonketotic reaction; squeeze glucagon gel in buccal cavity.
- D. hypoglycemic reaction; give ordered insulin.
Correct Answer: A
Rationale: Hypoglycemic reaction is due to not enough food for the insulin. Quick acting carbohydrates - such as orange juice or longer acting foods such as milk, crackers, and cheese-are beneficial.
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A patient has undergone tests that indicate a deficiency of the parathyroid hormone secretion. The nurse will inform the patient of which potential complication?
- A. Osteoporosis
- B. Lethargy
- C. Laryngeal spasms
- D. Kidney stones
Correct Answer: C
Rationale: Decreased parathyroid hormone levels in the bloodstream cause a decreased calcium level. Severe hypocalcemia may result in laryngeal spasm, stridor, cyanosis, and increased possibility of asphyxia.
When the nurse inflates the sphygmomanometer cuff exceeding the systolic blood pressure and observes a carpal spasm, this is a(n) ___ sign.
Correct Answer: Trousseau
Rationale: Trousseau's sign is a carpal spasm brought on by pressure of a cuff. This is an indicator for hypocalcemia and hypomagnesemia.
Which action will the nurse take for the postoperative care of the patient who had a thyroidectomy?
- A. Assessing ability to speak by asking him or her to recite name and address every hour
- B. Maintaining anatomic position of the head when moving a patient
- C. Assisting a patient to hyperextend the head to assess for muscle damage
- D. Doing voice check every 2 hours
- E. Turning, coughing every hour
- F. Checking for bleeding at the sides and the back of the head
Correct Answer: B,D,F
Rationale: The nurse should hold the head in an anatomic position when moving the patient to prevent tension on the suture line, do a voice check every 2 to 4 hours by asking the patient to say 'ah'; the patient is not turned nor is coughing recommended immediately after a thyroidectomy.
Which test will furnish immediate feedback for a newly diagnosed diabetic who is not yet under control?
- A. Fasting blood sugar (FBS)
- B. Glycosylated hemoglobin (HbA1c)
- C. Oral glucose tolerance test (OGTT)
- D. Clinitest
Correct Answer: A
Rationale: Diabetics should do a finger-stick blood glucose level test before each meal and at bedtime each day until their disease is under control. The HbA1c serum test reveals the effectiveness of diabetes therapy for the preceding 8 to 12 weeks.
A patient with a history of Graves' disease is admitted to the unit with shortness of breath. The nurse notes the patient's vital signs: T 103°F, P 160, R 24, BP 160/80. The nurse also notes distended neck veins. Which disorder does the patient most likely have?
- A. Pulmonary embolism
- B. Hypertensive crisis
- C. Thyroid storm
- D. Cushing crisis
Correct Answer: C
Rationale: In a thyroid crisis, all the signs and symptoms of hyperthyroidism are exaggerated. Additionally, the patient may develop nausea, vomiting, severe tachycardia, severe hypertension, and occasionally hyperthermia up to 41°C (106°F). Extreme restlessness, cardiac arrhythmia, and delirium may also occur. The patient may develop heart failure and may die.