Nokea
The nurse is caring for a client with DM who is experiencing ketoacidosis. The nurse should prioritize which action?
- A. Administering insulin intravenously.
- B. Giving the client sips of water.
- C. Monitoring the client's urine output.
- D. Applying a heating pad to the client's abdomen.
Correct Answer: A
Rationale: Administering insulin intravenously is the priority action for managing diabetic ketoacidosis. Insulin helps lower blood glucose levels and halts the production of ketones, addressing the underlying cause of ketoacidosis. Giving sips of water (Choice B) may be necessary for hydration, but it does not address the immediate life-threatening issue of ketoacidosis. Monitoring urine output (Choice C) is important for assessing renal function but is not the priority over administering insulin. Applying a heating pad (Choice D) is not indicated and can potentially worsen the condition in ketoacidosis.
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A client with Cushing's syndrome is being monitored for complications. Which of the following findings should the nurse report to the healthcare provider immediately?
- A. Hypertension
- B. Hyperglycemia
- C. Low-grade fever
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Low-grade fever. A low-grade fever may indicate an infection, which is a serious concern in clients with Cushing's syndrome due to their immunosuppressed state. Hypertension and hyperglycemia are common manifestations of Cushing's syndrome and may not require immediate reporting unless severe or uncontrolled. Weight gain is also a common symptom in clients with Cushing's syndrome and may not warrant immediate reporting unless it is sudden and significant.
Which of the following is a priority nursing diagnosis for a client with Addison's disease?
- A. Fluid volume deficit
- B. Risk for infection
- C. Imbalanced nutrition: Less than body requirements
- D. Disturbed body image
Correct Answer: A
Rationale: The priority nursing diagnosis for a client with Addison's disease is 'Fluid volume deficit.' Addison's disease is characterized by adrenal insufficiency, resulting in decreased aldosterone production. Aldosterone plays a key role in sodium and water retention in the body. With its deficiency, there is an increased risk of dehydration and electrolyte imbalance, leading to fluid volume deficit. While infection risk, nutrition issues, and body image disturbances are also important considerations for holistic care, addressing the fluid volume deficit takes precedence due to the immediate physiological impact on the client's health and well-being.
An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, Nurse Libby prepares to take emergency action to prevent the potential complication of:
- A. Thyroid storm.
- B. Cretinism.
- C. Myxedema coma.
- D. Hashimoto's thyroiditis.
Correct Answer: C
Rationale: The scenario described with hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area is indicative of myxedema coma, a severe and life-threatening complication of hypothyroidism. Myxedema coma requires immediate emergency treatment to prevent further deterioration. Choice A, thyroid storm, is a complication of hyperthyroidism characterized by an increase in body temperature, heart rate, and blood pressure. Choice B, cretinism, refers to untreated congenital hypothyroidism leading to mental and physical growth retardation. Choice D, Hashimoto's thyroiditis, is an autoimmune condition leading to hypothyroidism but does not present with the acute, life-threatening symptoms described in the scenario.
Which of the following best describes the nurse's role in patient education?
- A. The nurse is responsible for providing patients with information they need to make informed decisions about their care.
- B. The nurse provides education to the patient and their family to help them understand the care plan and make informed decisions.
- C. The nurse is responsible for providing patients with written materials to help them understand their condition and treatment options.
- D. The nurse provides patients with verbal and written instructions on how to manage their care at home.
Correct Answer: A
Rationale: The correct answer is A. The nurse's role in patient education involves providing patients with the necessary information to make informed decisions about their care. This includes explaining treatment options, potential risks and benefits, and answering any questions the patient may have. Choice B is incorrect because while nurses do educate patients and families, the primary focus is on empowering patients to make informed decisions. Choice C is incorrect as providing written materials is a part of patient education but not the sole responsibility of the nurse. Choice D is incorrect because while nurses do provide instructions on managing care at home, patient education goes beyond just the home care aspect to encompass a broader understanding of the patient's condition and treatment.
A client with hyperparathyroidism is at risk for which of the following complications?
- A. Hypocalcemia
- B. Osteoporosis
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: B
Rationale: A client with hyperparathyroidism is at risk for osteoporosis, not hypocalcemia, hypokalemia, or hyponatremia. Hyperparathyroidism results in increased levels of parathyroid hormone, which causes excessive breakdown of bone tissue to release calcium into the bloodstream. This process can lead to weakened bones and an increased risk of osteoporosis. Hypocalcemia is unlikely in hyperparathyroidism as the condition is characterized by elevated calcium levels due to the abnormal activity of the parathyroid glands. Hypokalemia and hyponatremia are not directly associated with hyperparathyroidism; they are more commonly linked to other conditions affecting potassium and sodium levels in the body.