Nokea
The nurse is caring for clients on a medical floor. Which client should be assessed first?
- A. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday.
- B. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours.
- C. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching.
- D. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.
Correct Answer: C
Rationale: Muscle twitching in SIADH suggests hyponatremia-induced neurological symptoms, requiring immediate assessment. Weight gain, slight DI output imbalance, and tiredness are less urgent.
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Preoperatively, which information is most important to teach the client before the subtotal thyroidectomy?
- A. Techniques for changing positions
- B. Reasons for performing leg exercises
- C. The necessity for daily dressing changes
- D. Postoperative use of the incentive spirometer
Correct Answer: D
Rationale: Using an incentive spirometer postoperatively helps prevent respiratory complications after thyroidectomy.
Which sign is most suggestive that a client with type 2 diabetes is developing hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. The client's serum glucose level is 650 mg/dL.
- B. The client's urinary output is 3,000 mL/24 hours.
- C. The client's skin is cool and moist.
- D. The client's urine contains acetone.
Correct Answer: A
Rationale: A serum glucose level of 650 mg/dL is characteristic of HHNS, indicating severe hyperglycemia.
The nurse is teaching the client newly diagnosed with type 2 DM. Which information should the nurse emphasize in the session?
- A. Use the arm when self-administering insulin.
- B. Exercise for 30 minutes daily, preferably after a meal.
- C. Consume 30% of the daily calorie intake from protein foods.
- D. Eat a 30-gram carbohydrate snack prior to strenuous activity.
Correct Answer: B
Rationale: Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise contributes to weight loss, which also decreases insulin resistance.
An 18-year-old female client, 5'4 tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed?
- A. Type 1 diabetes.
- B. Type 2 diabetes.
- C. Gestational diabetes.
- D. Acanthosis nigricans.
Correct Answer: B
Rationale: Obesity (BMI ~44) and a nonhealing wound suggest type 2 diabetes, associated with insulin resistance. Type 1 is less likely, gestational diabetes requires pregnancy, and acanthosis nigricans is a symptom, not a disease.
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.