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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.
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The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider?
- A. Serum sodium of 112 mEq/L and a headache.
- B. Serum potassium of 5.0 mEq/L and a heightened awareness.
- C. Serum calcium of 10 mg/dL and tented tissue turgor.
- D. Serum magnesium of 1.2 mg/dL and large urinary output.
Correct Answer: A
Rationale: Severe hyponatremia (112 mEq/L) and headache in SIADH risk seizures, requiring immediate HCP notification. Other findings are less critical or unrelated.
The client diagnosed with diabetes complains of a curtain being drawn across the eyes. Which should the nurse implement first?
- A. Assess the eyes using an ophthalmoscope.
- B. Tell the client to keep the eyes closed.
- C. Notify the health-care provider (HCP).
- D. Call the Rapid Response Team (RRT).
Correct Answer: C
Rationale: A curtain-like vision loss suggests retinal detachment, a diabetic complication requiring urgent HCP notification. Ophthalmoscopy, closing eyes, or RRT are inappropriate first steps.
The nurse is caring for the client with SIADH. Which interventions should the nurse plan to implement? Select all that apply.
- A. Obtain the weight near the same time each morning.
- B. Place the client on a fluid-restricted diet as prescribed.
- C. Prepare to give a 500-mL NaCl intravenous fluid bolus.
- D. Administer furosemide intravenously as prescribed.
- E. Monitor for hyperactive reflexes and heightened alertness.
Correct Answer: A,B,D
Rationale: Daily weights monitor fluid retention, fluid restriction treats hyponatremia, and furosemide addresses fluid overload in SIADH.
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.
What is the nursing priority when administering care to a client with severe hyperthyroidism?
- A. Assess for recent emotional trauma.
- B. Provide a calm, nonstimulating environment.
- C. Provide diversionary activity.
- D. Encourage range-of-motion exercises.
Correct Answer: B
Rationale: A calm, nonstimulating environment reduces hyperactivity and stress in hyperthyroidism, which exacerbates symptoms.