Nokea
The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse?
- A. The client has crumbling toenails.
- B. The client has athlete's foot.
- C. The client has a necrotic big toe.
- D. The client has thickened toenails.
Correct Answer: C
Rationale: A necrotic big toe indicates severe infection or gangrene, requiring immediate intervention to prevent amputation. Crumbling/thickened nails and athlete’s foot are less urgent.
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As the nurse provides care for the client newly diagnosed with a large goiter, which interventions should be implemented? Select all that apply.
- A. Observe the client's respiratory status
- B. Elevate the head of the client's bed
- C. Provide a diet high in food used.
- D. Obtain an order for a soft diet
- E. Assess for high fever
- F. Administer prescribed antibiotics
Correct Answer: A,B,D
Rationale: A large goiter can compress the trachea, necessitating respiratory monitoring, head elevation, and a soft diet to ease swallowing.
The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement?
- A. Assess for dehydration and monitor blood glucose levels.
- B. Assess for nausea and vomiting and weigh daily.
- C. Monitor potassium levels and encourage fluid intake.
- D. Administer vasopressin IV and conduct a fluid deprivation test.
Correct Answer: B
Rationale: Nausea/vomiting and daily weights monitor SIADH complications (e.g., hyponatremia, fluid overload). Dehydration is unlikely, potassium is less critical, and vasopressin worsens SIADH.
The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client?
- A. Diabetes insipidus (DI).
- B. Crohn's disease.
- C. Narcotic addiction.
- D. Peritonitis.
Correct Answer: C
Rationale: Chronic pancreatitis often requires long-term pain management, risking narcotic addiction. DI, Crohn’s, and peritonitis are unrelated complications.
The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client?
- A. Refer the client to the American Diabetes Association.
- B. Do not take any over-the-counter (OTC) medications.
- C. Take the prescribed insulin even when unable to eat because of illness.
- D. Explain the need to get the annual flu and pneumonia vaccines.
Correct Answer: C
Rationale: Continuing insulin during illness prevents DKA by maintaining glucose control. ADA referral, avoiding OTC meds, and vaccines are secondary.
The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that apply.
- A. Notify the HCP if a three (3)-pound weight loss occurs in two (2) days.
- B. Discuss ways to cope with the emotional lability.
- C. Notify the HCP if taking over-the-counter medication.
- D. Carry a medical identification card or bracelet.
- E. Teach how to take thyroid medications correctly.
Correct Answer: B,C,D
Rationale: Coping with emotional lability, reporting OTC meds, and carrying ID address hyperthyroidism’s effects and safety. Rapid weight loss is expected, and thyroid meds are for hypothyroidism.