Nokea
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.
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The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented?
- A. Administer sliding-scale insulin as ordered.
- B. Restrict caffeinated beverages.
- C. Check urine ketones if blood glucose is >250.
- D. Assess tissue turgor every four (4) hours.
Correct Answer: D
Rationale: Assessing tissue turgor monitors dehydration in DI due to excessive urine output. Insulin, ketones, and caffeine restriction are diabetes mellitus-related, not DI.
The nurse is planning a program for clients at a health fair regarding the prevention and early detection of cancer of the pancreas. Which self-care activity should the nurse discuss as an example of a primary nursing intervention?
- A. Monitor for elevated blood glucose at random intervals.
- B. Inspect the skin and sclera of the eyes for a yellow tint.
- C. Limit meat in the diet and eat a diet low in fat.
- D. Instruct the client with hyperglycemia about insulin injections.
Correct Answer: C
Rationale: A low-fat diet reduces pancreatic stress, a primary prevention strategy. Glucose monitoring, jaundice inspection, and insulin teaching are secondary or tertiary.
The nurse identifies the client problem 'risk for imbalanced body temperature' for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care?
- A. Discourage the use of an electric blanket.
- B. Assess the client's temperature every two (2) hours.
- C. Keep the room temperature cool.
- D. Space activities to promote rest.
Correct Answer: A
Rationale: Hypothyroidism causes cold intolerance; discouraging electric blankets prevents burns due to reduced sensation. Frequent temperature checks, cool rooms, and rest are less relevant.
The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement?
- A. Instruct the UAP to get the client additional food.
- B. Notify the dietitian about the client's request.
- C. Request the HCP increase the client's caloric intake.
- D. Tell the UAP the client cannot have anything else.
Correct Answer: B
Rationale: Notifying the dietitian ensures the client’s nutritional needs are met within DKA dietary restrictions. Additional food, caloric increases, or denial are inappropriate without consultation.
The client newly diagnosed with hyperthyroidism has a fever of 101.3°F (38.5°C). Which additional assessment findings should the nurse identify as those associated with thyroid storm? Select all that apply.
- A. Hypoventilation
- B. Heart rate 140 bpm
- C. Diarrhea last 4 days
- D. Periorbital edema
- E. Recent tooth extraction
Correct Answer: B,C,E
Rationale: Tachycardia, diarrhea, and recent stress (e.g., tooth extraction) are associated with thyroid storm due to excessive thyroid hormone.