Nokea
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.
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The nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 am to the client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct?
- A. The onset of the regular insulin will be at 7:45 am and the peak at 1:00 pm.
- B. The onset of the regular insulin will be at 8:00 am and the peak at 10:00 am.
- C. The onset of the NPH insulin will be at 8:00 am and the peak at 10:00 am.
- D. The onset of the NPH insulin will be at 12:30 pm and the peak at 11:30 pm.
Correct Answer: B
Rationale: The onset of regular insulin (short acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours.
Which client statement indicates the need for further teaching about thyroidectomy postoperative care?
- A. I should support my neck when sitting up.
- B. I may need calcium supplements.
- C. I can resume normal activities immediately.
- D. I should report any voice changes.
Correct Answer: C
Rationale: Resuming normal activities immediately post-thyroidectomy is incorrect due to the risk of complications like bleeding or hypocalcemia.
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.
An elderly client with Type 2 diabetes mellitus develops an ingrown toenail. What is the best action for the nurse to take?
- A. Put cotton under the nail and clip the nail straight across
- B. Elevate the foot immediately
- C. Apply warm, moist soaks
- D. Notify the physician
Correct Answer: D
Rationale: An ingrown toenail in a diabetic client risks infection and poor healing, requiring physician evaluation rather than self-treatment.
Which assessment findings would the nurse expect to document the patient's health care, and the patient's health care? Select all that apply.
- A. The client is hypertensive and tachycardic.
- B. The client is dyspneic and hypotensive.
- C. The client breathes noisily and smells of acetone.
- D. The client stares blankly and smells of alcohol.
- E. The client has warm, flushed skin and has vomited.
- F. The client complains of abdominal pain and is thirsty.
Correct Answer: C,E,F
Rationale: DKA is characterized by acetone breath, warm/flushed skin, vomiting, abdominal pain, and thirst due to hyperglycemia and dehydration.