Nokea
The nurse is collecting information about the client who underwent a transsphenoidal removal of a pituitary tumor. Which findings should indicate to the nurse that the client is experiencing DI? Select all that apply.
- A. Serum osmolality 310 mOsm/kg
- B. Weight increased 2 kg in 24 hours
- C. Experiencing an extreme thirst
- D. Urine output 4200 mL in 24 hours
- E. BP averaging 164/92 mm Hg or higher
Correct Answer: A,C,D
Rationale: Elevated serum osmolality, extreme thirst, and high urine output indicate DI due to fluid loss and ADH deficiency.
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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.
The nurse teaches the client how the infusion pump operates and correctly points out that the infusion is typically administered in which location?
- A. In a vein within the nondominant hand
- B. In the muscular tissue of the thigh
- C. In the subcutaneous tissue of the abdomen below the belt line
- D. In an implanted I.V. catheter threaded into the neck
Correct Answer: C
Rationale: Insulin pumps deliver insulin into the subcutaneous tissue of the abdomen for consistent absorption.
Which laboratory data make the nurse suspect the client with primary hyperparathyroidism is experiencing a complication?
- A. A serum creatinine level of 2.8 mg/dL.
- B. A calcium level of 9.2 mg/dL.
- C. A serum triglyceride level of 130 mg/dL.
- D. A sodium level of 135 mEq/L.
Correct Answer: A
Rationale: Elevated creatinine (2.8 mg/dL) suggests kidney damage, a complication of hyperparathyroidism’s hypercalcemia. Normal calcium, triglycerides, and sodium are unremarkable.
The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership?
- A. Call a meeting and educate the staff on the new delivery system being used.
- B. Organize a committee to investigate the various types of delivery systems.
- C. Wait until another unit has implemented the new system and see if it works out.
- D. Discuss with the nursing staff if a new delivery system should be adopted.
Correct Answer: A
Rationale: An autocratic leader unilaterally decides and informs staff, as in educating them on a chosen system. Committees, waiting, and staff discussions are democratic or laissez-faire.
Which nursing interventions are most appropriate for nursing in the health of a client with Cushing's syndrome? Select all that apply.
- A. Have the client sleep on a convoluted (egg-crate) foam mattress.
- B. Ambulate the client at frequent intervals.
- C. Advise the client to ask for assistance when getting up.
- D. Offer high-carbohydrate nourishment.
- E. Check the client frequently for suicidal ideation.
- F. Instruct the client to wear loose-fitting clothing.
Correct Answer: A,C,E,F
Rationale: These interventions address skin breakdown, fall risk, mood changes, and comfort in Cushing's syndrome.