Nokea
The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem 'high risk for hyperglycemia related to noncompliance with the medication regimen.' Which statement is an appropriate short-term goal for the client?
- A. The client will have a blood glucose level between 90 and 140 mg/dL.
- B. The client will demonstrate appropriate insulin injection technique.
- C. The nurse will monitor the client's blood glucose levels four (4) times a day.
- D. The client will maintain normal kidney function with 30-mL/hr urine output.
Correct Answer: B
Rationale: Demonstrating correct insulin injection technique addresses noncompliance, a short-term, client-centered goal. Glucose levels and kidney function are outcomes, and nurse monitoring is not client-focused.
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The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention?
- A. The client is alert to name but is unable to tell the nurse the location.
- B. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL.
- C. The client's vital signs are T 97.6°F, P 88, R 20, and BP 130/80.
- D. The client has a 3-cm amount of dark-red drainage on the turban dressing.
Correct Answer: B
Rationale: High output (2,500 mL vs. 1,000 mL intake) suggests diabetes insipidus, requiring immediate intervention to prevent dehydration. Disorientation, normal vitals, and drainage are less urgent.
The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
- A. Serum blood glucose level of 74 mg/dL.
- B. Pulse oximeter reading of 90%.
- C. Telemetry reading showing sinus bradycardia.
- D. The client is lethargic and sleeps all the time.
Correct Answer: B
Rationale: A pulse oximetry of 90% indicates hypoxia, requiring immediate intervention in myxedema coma. Normal glucose, bradycardia, and lethargy are expected.
Which instruction should the nurse give the client about insulin administration during periods of illness?
- A. Monitor blood glucose levels every 2 to 4 hours.
- B. Eat candy or sugar frequently.
- C. Attempt to drink a high-calorie beverage every hour.
- D. Test urine daily for protein.
Correct Answer: A
Rationale: Frequent blood glucose monitoring during illness helps adjust insulin doses to prevent complications.
The nurse is interviewing four clients. Which client is at the greatest risk for developing type 2 DM?
- A. 56-year-old Hispanic female
- B. 40-year-old Asian American female
- C. 25-year-old obese Caucasian male
- D. 38-year-old Native American male
Correct Answer: D
Rationale: Research has shown that the highest incidence of DM is among Native Americans.
The nurse is preparing to care for the stable client with Addison's disease. Which skin appearance should the nurse expect when performing an assessment?
- A. Very white, dry, and scaly
- B. Bronzed and suntanned hue
- C. Diaphoretic and cyanotic
- D. Puffy and butterfly-like rash
Correct Answer: B
Rationale: The nurse should expect a bronzed, suntanned hue due to increased melanocyte-stimulating hormone in Addison's disease.