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The nurse is reviewing serum laboratory results for four female clients. Place an X on the client requiring the most immediate assessment.
- A. Client A: TSH 5.2 mIU/L, Free T4 0.8 ng/dL
- B. Client B: GH 23 µg/L, IGF-I 490 ng/mL
- C. Client C: Free T4 7.0 ng/dL, TSH 0.1 mIU/L
- D. Client D: Fasting glucose 140 mg/dL, Hgb A1c 6.9%
Correct Answer: C
Rationale: Client C has elevated free T4 and decreased TSH, indicating hyperthyroidism, which can lead to life-threatening thyroid storm with severe hypertension and tachycardia, requiring immediate assessment.
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The nurse at a freestanding health-care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy?
- A. Ask the client if he has somewhere he can go and live.
- B. Arrange for someone to give him insulin at a local homeless shelter.
- C. Notify Adult Protective Services about the client's situation.
- D. Ask the HCP to take the client off insulin because he is homeless.
Correct Answer: B
Rationale: Arranging insulin administration at a shelter ensures the client’s medical needs are met, advocating for his health. Housing questions, APS notification, and stopping insulin are less supportive.
The nurse is teaching the client who lacks parathyroid hormone (PTH) about foods to consume. Which items should be included on a list of appropriate foods for the client?
- A. Dark green vegetables, soybeans, and tofu
- B. Spinach, strawberries, and yogurt
- C. Whole grain bread, milk, and liver
- D. Rhubarb, yellow vegetables, and fish
Correct Answer: A
Rationale: High-calcium foods like dark green vegetables, soybeans, and tofu are appropriate for hypoparathyroidism to address chronic hypocalcemia.
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.
When given the news, the client denies the diagnosis and becomes angry, stating there has been a mistake in the tests. Which nursing action is most appropriate at this time?
- A. Emphasizing the importance of treatment
- B. Reassuring the client that the disease is easily managed
- C. Explaining that many people live with diabetes
- D. Listening as the client expresses current feelings
Correct Answer: D
Rationale: Listening to the client's feelings supports emotional processing and acceptance of the diagnosis.
If the following foods are available, which one should the nurse recommend?
- A. Cheddar cheese
- B. Raw carrots
- C. Canned fruit
Correct Answer: A
Rationale: Cheddar cheese is high in sodium, which is beneficial for clients with Addison's disease to replace sodium loss.