Nokea
The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition?
- A. Daily weight
- B. Fingerstick glucose
- C. Lung sound auscultation
- D. Urine osmolality
Correct Answer: D
Rationale: The correct answer is D: Urine osmolality. In head trauma patients, the risk of developing diabetes insipidus (DI) is high due to damage to the posterior pituitary. Monitoring urine osmolality helps identify DI early, as low urine osmolality indicates impaired concentration ability. This is crucial for prompt treatment to prevent dehydration. Choices A and B are important but not specific to endocrine disorders. Choice C is relevant for respiratory assessment, not endocrine disorders.
You may also like to solve these questions
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
- A. contact the provider and expect a prescription for a normal saline bolus.
- B. wait until the provider makes rounds to report the assessment findings.
- C. continue to evaluate urine output for 2 more hours.
- D. ignore the urine output, as this is most likely postrenal in origin.
Correct Answer: A
Rationale: Rationale:
1. Urine output < 20 mL/hour indicates potential hypoperfusion.
2. Decreased urine output with hypotension and tachycardia suggests inadequate fluid resuscitation.
3. Administering a normal saline bolus can help improve perfusion and stabilize blood pressure.
4. Contacting the provider promptly for orders is crucial in managing this acute situation.
Summary of Incorrect Choices:
B. Delaying reporting to the provider risks worsening the patient's condition.
C. Continuing to evaluate urine output without intervention can lead to further deterioration.
D. Ignoring the urine output due to potential postrenal causes overlooks the urgent need for fluid resuscitation.
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?
- A. An 18-year-old college student with type 1 diabetes who exercises excessively
- B. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
- C. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections
- D. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza
Correct Answer: D
Rationale: The correct answer is D because the 83-year-old long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza is at the highest risk for hyperosmolar hyperglycemic syndrome (HHS). This patient has multiple risk factors for HHS, including age, type 2 diabetes, advanced Alzheimer's disease, and the added stress of influenza, which can exacerbate hyperglycemia. The combination of these factors can lead to severe hyperglycemia, dehydration, and electrolyte imbalances characteristic of HHS.
Choice A is incorrect because although excessive exercise can lead to hypoglycemia in individuals with type 1 diabetes, it is not a risk factor for HHS. Choice B is incorrect as forgetting to take insulin can lead to diabetic ketoacidosis in type 1 diabetes, not HHS. Choice C is incorrect as starting insulin injections in a patient with type 2 diabetes and coronary artery disease does not automatically increase the risk
The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should
- A. assess that the blood tubing is warm to the touch.
- B. assess the hemofilter every 6 hours for clotting.
- C. cover the dialysis lines to protect them from light.
- D. use clean technique during vascular access dressing changes.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Hemofilter clotting can affect CRRT efficiency.
2. Assessing every 6 hours allows early detection and intervention.
3. Clotting can lead to treatment interruptions or complications.
4. Regular assessment ensures optimal therapy delivery.
Other Choices:
A: Assessing tubing warmth is not a reliable indicator of CRRT function or complications.
C: Covering dialysis lines to protect from light is not a standard practice in CRRT monitoring.
D: Using clean technique is not sufficient for vascular access dressing changes; aseptic technique is required for infection prevention.
An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual’s priority action?
- A. Drink additional water to prevent dehydration.
- B. Eat something with 15 g of simple carbohydrates.
- C. Go to the first-aid station to have glucose checked.
- D. Take another dose of the oral agent.
Correct Answer: B
Rationale: The correct answer is B: Eat something with 15 g of simple carbohydrates. In this scenario, the individual is exhibiting signs of hypoglycemia due to the combination of glipizide (which can lower blood sugar) and exercise. The priority action is to raise blood sugar levels quickly to prevent further complications. Consuming simple carbohydrates, like glucose tablets or juice, will rapidly increase blood sugar levels. This is crucial to prevent the individual from passing out or experiencing more serious consequences.
Choice A is incorrect because while hydration is important, it is not the immediate priority in this situation. Choice C is incorrect as going to the first-aid station may waste valuable time when immediate action is needed. Choice D is incorrect as taking another dose of the oral agent can further lower blood sugar levels and worsen the hypoglycemia.
The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate
- A. increased nitrogen intake.
- B. acute kidney injury, such as acute tubular necrosis (ATN).
- C. hypovolemia.
- D. fluid resuscitation.
Correct Answer: B
Rationale: The elevated BUN and serum creatinine levels with a normal BUN/creatinine ratio suggest kidney dysfunction. This pattern is commonly seen in acute kidney injury, like acute tubular necrosis (ATN), where the kidneys are unable to properly filter waste products. Other choices (A) increased nitrogen intake and (C) hypovolemia would not cause the specific pattern of elevated BUN and creatinine levels with a normal ratio. (D) Fluid resuscitation would actually aim to correct hypovolemia and would not directly affect the BUN and creatinine levels.