Nokea
Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?
- A. Excessive thirst.
- B. Orthopnea.
- C. Ascites.
- D. Concentrated urine output.
Correct Answer: D
Rationale: SIADH causes excessive ADH, leading to water retention, hyponatremia, and concentrated urine output due to reduced urine volume. Excessive thirst is typical of diabetes insipidus, orthopnea relates to heart failure, and ascites is linked to liver disease.
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The nurse is teaching a client to self-administer insulin. The instructions should include teaching the client to:
- A. inject the needle at a 90-degree angle into the muscle.
- B. vigorously massage the area after injecting the insulin.
- C. rotate injection sites.
- D. keep the open bottle of insulin in the refrigerator.
Correct Answer: C
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption. Insulin is injected subcutaneously, not into muscle, and massaging can alter absorption.
Which client problem is the nurse’s priority concern for the client diagnosed with acute pancreatitis?
- A. Impaired nutrition.
- B. Skin integrity
- C. Anxiety
- D. Pain relief.
Correct Answer: D
Rationale: Acute pancreatitis is characterized by severe abdominal pain due to pancreatic inflammation and autodigestion. Pain relief is the priority concern, as it addresses the client’s immediate discomfort, improves patient comfort, and reduces physiological stress, which can exacerbate the condition. Using the ABCs (Airway, Breathing, Circulation) and Maslow’s hierarchy, pain is a physiological need that takes precedence. Impaired nutrition (1) is relevant but secondary, as clients are often NPO initially. Skin integrity (2) and anxiety (3) are lower priorities, as they are less immediate concerns in acute pancreatitis.
The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care?
- A. Assess the client's ability to read small print.
- B. Monitor the client's serum prothrombin time (PT) level.
- C. Teach the client how to perform a hemoglobin A1c test daily.
- D. Instruct the client to check the feet weekly.
Correct Answer: A
Rationale: Assessing the ability to read small print ensures the elderly client can read insulin labels and glucometer results, critical for safe management. PT is irrelevant, A1c is not daily, and foot checks are daily.
The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered?
- A. Plasma drug levels of quinidine, digoxin, and hydralazine.
- B. Plasma levels of ACTH and cortisol.
- C. A 24-hour urine for metanephrine and catecholamine.
- D. Spot urine for creatinine and white blood cells (WBCs).
Correct Answer: B
Rationale: ACTH and cortisol levels diagnose Cushing’s by confirming hypercortisolism. Other tests assess unrelated conditions (e.g., pheochromocytoma, renal function).
Based on the client's blood glucose measurement, the nurse immediately reevaluates the client. Which physician orders should the nurse anticipate? Select all that apply.
- A. STAT serum blood glucose
- B. Intravenous regular insulin
- C. Vital signs every 2 hours
- D. A diet of six small, frequent meals
- E. Electronic glucometer measurements before meals and at bedtime
- F. Continuous cardiac monitoring
Correct Answer: A,B,E,F
Rationale: DKA with a glucose of 498 mg/dL requires STAT serum glucose, IV insulin, frequent glucometer checks, and cardiac monitoring.