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The nurse writes a problem of 'altered body image' for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented?
- A. Monitor blood glucose levels prior to meals and at bedtime.
- B. Perform a head-to-toe assessment on the client every shift.
- C. Use therapeutic communication to allow the client to discuss feelings.
- D. Assess bowel sounds and temperature every four (4) hours.
Correct Answer: C
Rationale: Therapeutic communication addresses body image concerns (e.g., moon face, weight gain) in Cushing’s, promoting coping. Glucose, assessments, and bowel sounds are unrelated.
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Which action is the best indication that the client needs more practice in combining two insulins in one syringe?
- A. The client rolls the vial of intermediate-acting insulin to mix it with its additive.
- B. The client still have a little or less the fast-acting and intermediate-acting insulin vials.
- C. The client instills the intermediate-acting insulin into the vial of rapid-acting insulin.
- D. The client inverts each vial before withdrawing the specified amount of insulin.
Correct Answer: C
Rationale: Instilling insulin into another vial contaminates the medication and is incorrect.
When the client asks why a diabetic relative cannot take insulin orally, what is the best answer?
- A. Insulin is inactivated by digestive enzymes.
- B. Insulin is absorbed too quickly in the stomach.
- C. Insulin is irritating to the gastric mucosa.
- D. Insulin is incompatible with many foods.
Correct Answer: A
Rationale: Insulin is a protein that is broken down by digestive enzymes, rendering it ineffective if taken orally.
The nurse identified a concept of metabolism for a client diagnosed with diabetes mellitus type 2. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Teach the client to perform self glucose monitoring.
- B. Instruct the client about complications of high-glucose levels.
- C. Instruct the client to inspect the feet daily.
- D. Explain the need to carry a source of quick-acting proteins.
- E. Encourage the client to have regular eye exams.
Correct Answer: A,B,C,E
Rationale: Glucose monitoring, complication education, foot inspections, and eye exams manage type 2 diabetes and prevent complications. Quick-acting proteins are incorrect; carbohydrates treat hypoglycemia.
The nurse administers 15 units of glargine insulin at 2100 hours to the client when the client's fingerstick blood glucose reading is 110 mg/dL. At 2300, an NA reports that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate?
- A. You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime.'
- B. It is not necessary for this client to have a snack; glargine insulin is absorbed over 24 hours and doesn't have a peak.'
- C. The next time the client wakes up, check a blood glucose level and then give a 15-gram carbohydrate snack.'
- D. I will notify the HCP; a snack at this time will affect the next blood glucose level and dose of glargine insulin.'
Correct Answer: B
Rationale: The onset of glargine is 1 hour; it has no peak action, and it lasts for 24 hours. Because it has no peak action, a bedtime snack is unnecessary.
Which endocrine disorder should the nurse assess for in the client who has a closed head injury with increased intracranial pressure?
- A. Pheochromocytoma.
- B. Diabetes insipidus.
- C. Hashimoto’s thyroiditis.
- D. Gynecomastia.
Correct Answer: B
Rationale: Closed head injuries with increased intracranial pressure can impair the pituitary gland, leading to diabetes insipidus (DI) due to reduced antidiuretic hormone (ADH) secretion, causing polyuria and dehydration. Pheochromocytoma, Hashimoto’s, and gynecomastia are unrelated to head trauma.