Nokea
The nurse is assessing the client who has type 2 DM. Which findings indicate to the nurse that the client is experiencing HHNS? Select all that apply.
- A. Serum osmolality 364 mOsm/kg
- B. Blood glucose level 160 mg/dL
- C. Very dry mucous membranes
- D. Blood pressure of 90/42 mm Hg
- E. Urine output 500 mL past 8 hours
Correct Answer: A,C,D
Rationale: A serum osmolality of 364 mOsm/kg, very dry mucous membranes, and a BP of 90/42 indicate HHNS due to elevated osmolality, dehydration, and hypotension from osmotic diuresis.
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Based on the knowledge that clients with Cushing's syndrome heal slowly, which nursing measure is most appropriate during the client's postoperative period?
- A. Monitoring infusion of I.V. antibiotics
- B. Removing tape toward the incision site
- C. Increasing the client's dietary protein intake
- D. Covering the wound with gauze
Correct Answer: C
Rationale: Increased dietary protein supports tissue repair and healing in Cushing's syndrome.
The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
- A. Serum blood glucose level of 74 mg/dL.
- B. Pulse oximeter reading of 90%.
- C. Telemetry reading showing sinus bradycardia.
- D. The client is lethargic and sleeps all the time.
Correct Answer: B
Rationale: A pulse oximetry of 90% indicates hypoxia, requiring immediate intervention in myxedema coma. Normal glucose, bradycardia, and lethargy are expected.
Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?
- A. Excessive thirst.
- B. Orthopnea.
- C. Ascites.
- D. Concentrated urine output.
Correct Answer: D
Rationale: SIADH causes excessive ADH, leading to water retention, hyponatremia, and concentrated urine output due to reduced urine volume. Excessive thirst is typical of diabetes insipidus, orthopnea relates to heart failure, and ascites is linked to liver disease.
Which of the following provides the best evidence that the dietary measures to control functional hypoglycemia are therapeutic?
- A. The client experiences fewer incidences of weakness and tremors.
- B. The client experiences fewer incidences of thirst and dry mouth.
- C. The client experiences fewer incidences of muscle spasms and fatigue.
- D. The client experiences fewer incidences of hunger and abdominal cramps.
Correct Answer: A
Rationale: Reduced weakness and tremors indicate stabilized blood glucose levels in functional hypoglycemia.
The nurse is preparing to administer a.m. medications to clients. Which medication should the nurse question before administering?
- A. Pancreatic enzymes to the client who has finished breakfast.
- B. The pain medication, morphine, to the client who has a respiratory rate of 20.
- C. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L.
- D. The beta blocker to the client who has an apical pulse of 68 bpm.
Correct Answer: A
Rationale: Pancreatic enzymes should be taken with meals, not after, to aid digestion. Morphine, diuretics, and beta blockers are appropriate based on the data.