Nokea
Which nursing diagnosis should the nursing team consider when developing this client's care plan?
- A. Activity intolerance
- B. Self-care deficit
- C. Ineffective breathing
- D. Impaired swallowing
Correct Answer: B
Rationale: Acromegaly can cause joint pain and muscle weakness, contributing to self-care deficits.
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The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention?
- A. Administer the insulin that is due now.
- B. Call the lab for a STAT serum glucose level.
- C. Have the client choose foods for a meal now.
- D. Provide juice with 15 grams of carbohydrates.
Correct Answer: D
Rationale: Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.
Which diet does the nurse expect will be ordered for the client with hypothyroidism?
- A. High protein, high calorie
- B. Restricted fluids, low protein
- C. High roughage, low calorie
- D. High carbohydrate, low roughage
Correct Answer: C
Rationale: A high-roughage, low-calorie diet supports weight loss and relieves constipation in hypothyroidism.
Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism?
- A. Thyroid hormones.
- B. Oxygen.
- C. Sedatives.
- D. Laxatives.
Correct Answer: C
Rationale: Sedatives risk respiratory depression in untreated hypothyroidism due to slowed metabolism. Thyroid hormones, oxygen, and laxatives are appropriate.
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?
- A. Complaints of extreme fatigue and hair loss.
- B. Exophthalmos and complaints of nervousness.
- C. Complaints of profuse sweating and flushed skin.
- D. Tetany and complaints of stiffness of the hands.
Correct Answer: A
Rationale: Hypothyroidism causes fatigue and hair loss due to slowed metabolism. Exophthalmos/nervousness (hyperthyroidism), sweating, and tetany are unrelated.
Which statement by the client provides the best evidence that the client understands the principle of an exchange list for meal planning?
- A. I can eat one serving from each category on the exchange list per day.
- B. I record the patient's disease of food in each category are equal to one another.
- C. The number of servings from the exchange list is unlimited.
- D. I need to use the exchange list to determine the nutrition in food.
Correct Answer: B
Rationale: The exchange list groups foods with similar nutritional content, allowing equivalent substitutions.