Nokea
Which nursing intervention is essential for monitoring the client's condition?
- A. Measuring intake and output
- B. Muxying blood glucose levels
- C. Inserting a Foley catheter
- D. Sending urine samples to the laboratory
Correct Answer: A
Rationale: Monitoring intake and output is critical in diabetes insipidus to assess fluid balance and the severity of polyuria.
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Which laboratory data indicate to the nurse the client’s pancreatitis is improving?
- A. The amylase and lipase serum levels are decreased.
- B. The white blood cell (WBC) count is decreased.
- C. The conjugated and unconjugated bilirubin levels are decreased.
- D. The blood urea nitrogen (BUN) serum level is decreased.
Correct Answer: A
Rationale: Acute pancreatitis is characterized by elevated serum amylase and lipase levels due to pancreatic inflammation. A decrease in these levels indicates reduced pancreatic injury and improvement in the condition. While a decreased WBC count may suggest resolving infection, it is less specific. Bilirubin levels are relevant for biliary obstruction, not pancreatitis improvement, and BUN reflects renal function, not pancreatic status.
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.
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain?
- A. Recommend lying in the prone position with legs extended.
- B. Maintain a tripod position over the bedside table.
- C. Place in side-lying position with knees flexed.
- D. Encourage a supine position with a pillow under the knees.
Correct Answer: C
Rationale: Side-lying with knees flexed reduces abdominal tension, easing pancreatitis pain. Prone, tripod, and supine positions are less effective.
The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit?
- A. Kussmaul's respirations.
- B. Diarrhea and epigastric pain.
- C. Dry mucous membranes.
- D. Ketone breath odor.
Correct Answer: C
Rationale: HHNS causes severe dehydration, leading to dry mucous membranes. Kussmaul’s respirations and ketone odor are DKA-specific, and diarrhea/pain are less common.
Which laboratory test is most important for the nurse to monitor to determine how effectively the client's diabetes is being managed?
- A. Fasting blood glucose
- B. Blood chemistry profile
- C. Complete blood count
- D. Glycosylated hemoglobin (HbA1c)
Correct Answer: D
Rationale: HbA1c reflects average blood glucose control over 2-3 months, indicating long-term diabetes management.