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Which finding would be the greatest cause for concern to the nurse during the early postoperative period following a thyroidectomy?
- A. Temperature of 100°F
- B. A sore throat
- C. Carpal spasm when the blood pressure is taken
- D. Complaints of pain in the area of the surgical incision
Correct Answer: C
Rationale: Carpal spasm (Trousseau’s sign) indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid gland injury.
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The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement?
- A. Increase the regular insulin IV drip.
- B. Check the client's urine for ketones.
- C. Provide the client with a therapeutic diabetic meal.
- D. Notify the HCP to obtain an order to decrease insulin.
Correct Answer: D
Rationale: A glucose drop from 780 to 300 mg/dL requires HCP notification to adjust insulin, preventing hypoglycemia. Increasing insulin, checking ketones, or meals are inappropriate.
Which sign is most suggestive that a client with type 2 diabetes is developing hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. The client's serum glucose level is 650 mg/dL.
- B. The client's urinary output is 3,000 mL/24 hours.
- C. The client's skin is cool and moist.
- D. The client's urine contains acetone.
Correct Answer: A
Rationale: A serum glucose level of 650 mg/dL is characteristic of HHNS, indicating severe hyperglycemia.
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.
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.