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The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess?
- A. Moon face, buffalo hump, and hyperglycemia.
- B. Hirsutism, fever, and irritability.
- C. Bronze pigmentation, hypotension, and anorexia.
- D. Tachycardia, bulging eyes, and goiter.
Correct Answer: C
Rationale: Addison’s causes cortisol and aldosterone deficiency, leading to bronze pigmentation, hypotension, and anorexia. Other options describe Cushing’s, hyperthyroidism, or unrelated symptoms.
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Which statement indicates that a client with an elevated 2-hour postprandial blood glucose level understands the significance of the screening test?
- A. I need to eat less frequently.
- B. I need to consult my physician.
- C. I need to begin taking insulin.
Correct Answer: B
Rationale: An elevated postprandial glucose level warrants further medical evaluation by a physician.
The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply.
- A. Take diabetic medication even if unable to eat the client's normal diabetic diet.
- B. If unable to eat, drink liquids equal to the client's normal caloric intake.
- C. It is not necessary to notify the health-care provider (HCP) if ketones are in the urine.
- D. Test blood glucose levels and test urine ketones once a day and keep a record.
- E. Call the health-care provider if glucose levels are higher than 180 mg/dL.
Correct Answer: A,B
Rationale: Continuing insulin and consuming caloric liquids (e.g., juice) prevent DKA during illness. Ketones require HCP notification, daily testing is insufficient, and 180 mg/dL is too low for notification.
The client diagnosed with acute pancreatitis has a ruptured pseudocyst. Which procedure should the nurse anticipate the HCP prescribing?
- A. Paracentesis.
- B. Chest tube insertion.
- C. Lumbar puncture.
- D. Biopsy of the pancreas.
Correct Answer: A
Rationale: A ruptured pancreatic pseudocyst can cause peritoneal irritation or fluid accumulation, potentially requiring drainage. Paracentesis removes abdominal fluid, which may be performed in severe cases, though surgical drainage or endoscopic intervention is more specific. Chest tube insertion is for pleural issues, lumbar puncture is for cerebrospinal fluid, and pancreatic biopsy is diagnostic, not therapeutic for a ruptured pseudocyst.
Which client would the nurse identify as being at risk for developing diabetes?
- A. The client who eats mostly candy and potatoes.
- B. The 22-year-old client who has been taking birth control pills.
- C. The client who has a cousin who has had diabetes for two (2) years.
- D. The 38-year-old female who delivered a 10-pound infant.
Correct Answer: D
Rationale: Delivering a large infant (macrosomia) indicates gestational diabetes history, a strong risk factor for type 2 diabetes. Candy/potatoes, birth control, and family history are less specific.
Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm?
- A. Obstipation and hypoactive bowel sounds.
- B. Hyperpyrexia and extreme tachycardia.
- C. Hypotension and bradycardia.
- D. Decreased respirations and hypoxia.
Correct Answer: B
Rationale: Thyroid storm causes hyperpyrexia (high fever) and extreme tachycardia due to excessive thyroid hormone. Other options are hypothyroid or unrelated.