Nokea
The nurse is caring for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNKS). Which assessment finding should the nurse address immediately?
- A. Hypotension
- B. Blood pH 7.38
- C. Mental changes
- D. Fever
Correct Answer: A
Rationale: Hypotension in HHNKS indicates significant fluid loss from the extracellular compartment, requiring urgent correction to prevent coma or death. A normal pH (7.38) is not a concern, and while mental changes and fever are symptoms, they are less immediately life-threatening than fluid imbalance.
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The nurse is admitting a client with the diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNKS) following steroid therapy. Which sign(s) and symptom(s) would the nurse likely note? Select all that apply.
- A. High blood pressure
- B. Extreme thirst
- C. Bradycardia
- D. Poor skin turgor
- E. Acidosis
- F. Hypoglycemia
Correct Answer: B,D
Rationale: HHNKS presents with extreme thirst and dehydration (poor skin turgor) due to severe hyperglycemia and fluid shifts. High blood pressure is unlikely (hypotension is more common), bradycardia is incorrect (tachycardia occurs), acidosis is not typical (unlike DKA), and hypoglycemia is not associated with HHNKS.
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?
- A. Respirations of 12 breaths/minute
- B. Cloudy urine
- C. Blood sugar 170 mg/dL
- D. Fruity breath
Correct Answer: D
Rationale: Fruity breath indicates rising ketones and potential diabetic ketoacidosis, a life-threatening condition requiring immediate intervention to prevent complications like acidosis or renal shutdown. A blood sugar of 170 mg/dL is elevated but less critical, cloudy urine may suggest a UTI, and normal respirations are not a priority.
The nurse understands that a client with diabetes mellitus is at greater risk for developing which complication?
- A. Low blood pressure
- B. Urinary tract infections
- C. Lifelong obesity
- D. Elevated triglycerides
Correct Answer: B
Rationale: Elevated blood glucose and glycosuria create an environment conducive to bacterial growth, increasing the risk of urinary tract, skin, and vaginal infections. Obesity and elevated triglycerides are risk factors for type 2 diabetes, and low blood pressure is not a common complication.
The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?
- A. It carries glucose into body cells
- B. It aids in the process of gluconeogenesis.
- C. It stimulates the pancreatic hormone cells.
- D. It decreases the intestinal absorption of glucose.
Correct Answer: A
Rationale: Insulin's primary role is to facilitate glucose transport into cells for energy use and promote glycogen storage in the liver, inhibiting glycogen breakdown. It does not promote gluconeogenesis, stimulate pancreatic hormone cells, or affect intestinal glucose absorption.
A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?
- A. Glargine
- B. Regular
- C. NPH
- D. Lente
Correct Answer: B
Rationale: Regular insulin is used intravenously for DKA due to its rapid onset and ability to be infused continuously. Glargine, NPH, and Lente are long- or intermediate-acting insulins administered subcutaneously, unsuitable for acute DKA management.