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The nurse is performing an assessment on a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment findings would support the diagnosis of SIADH?
- A. Peripheral edema
- B. Excessive urine production
- C. Normal or slightly increased blood pressure
- D. Low urine specific gravity
Correct Answer: A, C
Rationale: SIADH causes water retention, leading to edema and normal or slightly elevated BP from fluid overload. Urine is concentrated (high specific gravity), not low, and output is reduced, not excessive.
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The nurse is assessing a client with hyperparathyroidism. Which of the following findings would support a diagnosis of hyperparathyroidism?
- A. nephrolithiasis
- B. hyperphosphatemia
- C. diarrhea
- D. halitosis
Correct Answer: A
Rationale: Hyperparathyroidism increases calcium levels, leading to kidney stones (nephrolithiasis). Phosphorus levels drop, not rise, and diarrhea and halitosis are unrelated to this condition.
The nurse is caring for a client newly diagnosed with Cushing's disease. Which of the following client statements requires follow-up?
- A. I will need to eat more potassium-rich foods.
- B. I will need more steroids during periods of stress.
- C. I will be at a higher risk for an infection.
- D. I should do weight-bearing exercises.
Correct Answer: A
Rationale: Cushing's causes hyperkalemia, so more potassium-rich foods are harmful and need follow-up. Extra steroids for stress, infection risk, and weight-bearing exercises are appropriate.
The nurse is teaching a client who has Graves' disease about self-management. Which of the following should the nurse include in the teaching plan?
- A. Stool softeners can be taken daily to prevent constipation.
- B. Thyroid replacement should be taken first thing in the morning.
- C. Report any significant weight gain while taking the antithyroid medication.
- D. Maintain the prescribed fluid restriction to prevent fluid overload.
Correct Answer: C
Rationale: In Graves' disease, antithyroid meds control hyperthyroidism; significant weight gain may signal overtreatment, needing reporting. Stool softeners, thyroid replacement, and fluid restriction are for hypothyroidism or other conditions.
The following scenario applies to the next 1 items
The nurse in physician's office is caring for a 41-year-old male
Item 1 of 1
Nurses' Notes
1100 - Client presents for a routine follow-up and a medication refill. Client has no acute concerns and reports full adherence to his prescribed medications. Vital signs: T 97.5° F (36.4° C), P 90, RR 18, BP 138/88, pulse oximetry reading 96% on room air.
Medical History
• diabetes mellitus (type 2)
• hyperlipidemia
• hypertension
• irritable bowel syndrome
Current Medications
• metformin 1 gram by mouth daily
• glipizide 5 mg by mouth daily, before breakfast
• lisinopril 40 mg by mouth daily
• multivitamin 1 tablet by mouth daily
• atorvastatin 80 mg by mouth daily
The nurse reviews the client's medical record. Please complete the sentence below from the list of options. Based on the August glycated hemoglobin A1C results the client is
- A. going to require a prescription for insulin.
- B. having frequent episodes of hyperglycemia.
- C. demonstrating evidence of good glucose control.
- D. None of the above
Correct Answer: C
Rationale: Without specific HbA1C results, stable type 2 diabetes with adherence to metformin and glipizide suggests good control, assuming prior results were within target (<7%).
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a 59-year-old female
Item 1 of 1
Nurses' Notes
0845: Morning capillary blood glucose obtained of 189 mg/dL (10.4 mmol/L). 4 units of lispro insulin administered per sliding scale. Vancomycin infusion started at this time in left peripheral vascular access device that was patent with positive blood return. Call bell placed within reach.
0950: The client alerted RN that they 'didn't feel good.' The client appeared pale, diaphoretic, and lethargic. The client's words became slurred, and she was disoriented, asking, "where am I?" 'The client's breakfast tray appeared untouched. The client's capillary blood glucose was obtained at 41 mg/dL (2.2 mmol/L). Glasgow coma scale: 13. Vital signs: T 98° F (36.7° C), P 108, RR 22, BP 150/86, pulse oximetry reading 95%. A rapid response was called because of the client's condition change.
1000: Rapid response team arrived at the bedside. Report was given to the rapid response nurse.
Medical History
• Diabetes mellitus, type I
• Hyperlipidemia
• Pericarditis
• Asthma
Orders
0700:
• Admit to medical/surgical for cellulitis
• vancomycin 1 g, IV, every 12 hours
• Resume all home medications
• Insulin lispro, sliding scale, before meals
• Consistent carbohydrate diet
• Daily labs: complete blood count and comprehensive metabolic panel
The rapid response nurse receives report from the primary nurse and reviews the medical record. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Keep the client NPO until mental status improves, Administer glucagon 1 mg intramuscular (IM), Have the client drink 8 ounces (240 mL) of skim milk, Stop the vancomycin infusion.
- B. Creatinine, Glasgow coma scale, Capillary blood glucose, Urinary ketones.
- C. Cerebrovascular accident, Diabetic ketoacidosis (DKA), Hypoglycemia, Vancoymycin infusion reaction.
Correct Answer: C, B, C, B
Rationale: Low glucose (41 mg/dL), pallor, and disorientation indicate hypoglycemia. Administer glucagon for rapid correction, monitor glucose and Glasgow coma scale to assess recovery.