Nokea
The nurse evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan?
- A. Eyes sunken and skin flushed
- B. Skin moist with rapid elastic recoil
- C. Serum potassium level is 3.3 mEq/L
- D. ABG results are pH 7.25, PaCO2 30, HCO3 17
Correct Answer: B
Rationale: Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving.
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Which question should the nurse ask when assessing the client for an endocrine dysfunction?
- A. Have you noticed any pain in your legs when walking?
- B. Have you had any unexplained weight loss?
- C. Have you noticed any change in your bowel movements?
- D. Have you experienced any joint pain or discomfort?
Correct Answer: B
Rationale: Unexplained weight loss is a hallmark symptom of endocrine disorders like hyperthyroidism or diabetes mellitus, making it a key assessment question. Leg pain relates to vascular issues, bowel changes are less specific, and joint pain is more musculoskeletal.
Which diet does the nurse expect will be ordered for the client with hypothyroidism?
- A. High protein, high calorie
- B. Restricted fluids, low protein
- C. High roughage, low calorie
- D. High carbohydrate, low roughage
Correct Answer: C
Rationale: A high-roughage, low-calorie diet supports weight loss and relieves constipation in hypothyroidism.
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?
- A. Recommend lying in the prone position with legs extended.
- B. Maintain a tripod position over the bedside table.
- C. Place in side-lying position with knees flexed.
- D. Encourage a supine position with a pillow under the knees.
Correct Answer: C
Rationale: Side-lying with knees flexed reduces abdominal tension, easing pancreatitis pain. Prone, tripod, and supine positions are less effective.
Which client action indicates a need for further teaching about insulin administration?
- A. Using a new needle for each injection
- B. Storing insulin in the refrigerator
- C. Checking blood glucose before injecting
- D. Injecting insulin into a lipodystrophic area
Correct Answer: D
Rationale: Injecting insulin into a lipodystrophic area can impair absorption, indicating a need for further teaching on site rotation.
The client is a 62-year-old woman who is 30 pounds overweight. She comes to the doctor's office complaining of headaches, frequent hunger, excessive thirst, and urination. The presenting complaints suggest that the nurse should assess for other signs of which condition?
- A. Hypothyroidism
- B. Acute pyelonephritis
- C. Addison's disease
- D. Diabetes mellitus
Correct Answer: D
Rationale: Headaches, polyphagia, polydipsia, and polyuria are classic symptoms of diabetes mellitus, especially in an overweight individual.