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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The diabetic client tells the nurse that breakfast is always skipped. Which response by the nurse is most appropriate?
- A. If you drink a glass of milk and eat a breakfast bar, that will be sufficient for breakfast.
- B. You should eat each meal and snack at the same time each day.
- C. If you skip breakfast, eat a high-calorie snack at midmorning.
- D. Wait to take your medication until you eat your first meal of the day.
Correct Answer: B
Rationale: Consistent meal timing is crucial for blood glucose control in diabetes.
The nurse is interviewing four clients. Which client is at the greatest risk for developing type 2 DM?
- A. 56-year-old Hispanic female
- B. 40-year-old Asian American female
- C. 25-year-old obese Caucasian male
- D. 38-year-old Native American male
Correct Answer: D
Rationale: Research has shown that the highest incidence of DM is among Native Americans.
Which client statement indicates a correct understanding of corticosteroid therapy for Addison's disease?
- A. I can stop the medication if I feel better.
- B. I need to take this medication daily.
- C. I should take it only during stress.
- D. I can double the dose if I'm sick.
Correct Answer: B
Rationale: Corticosteroid therapy for Addison's disease requires daily administration to replace deficient hormones and maintain physiological balance.
Which information is most important for the nurse to elicit from the client to effectively evaluate compliance with the prescribed therapy?
- A. The dosage and frequency of insulin administration
- B. The client's glucose monitoring records for the past week
- C. The client's weight and vital signs before the office interview
- D. The symptoms experienced in the past month
Correct Answer: B
Rationale: Glucose monitoring records provide direct evidence of blood glucose control and therapy compliance.
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.