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Which statement indicates that a client with an elevated 2-hour postprandial blood glucose level understands the significance of the screening test?
- A. I need to eat less frequently.
- B. I need to consult my physician.
- C. I need to begin taking insulin.
Correct Answer: B
Rationale: An elevated postprandial glucose level warrants further medical evaluation by a physician.
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The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care?
- A. Infuse 0.9% normal saline intravenously.
- B. Administer intermediate-acting insulin.
- C. Perform blood glucometer checks daily.
- D. Monitor arterial blood gas (ABG) results.
Correct Answer: A
Rationale: IV normal saline corrects severe dehydration in HHNS, a priority collaborative intervention. Insulin is secondary, daily glucose checks are insufficient, and ABGs are less critical in HHNS.
The nurse identified a concept of metabolism for a client diagnosed with diabetes. Which antecedent would be identified as placing the client at risk for diabetes?
- A. Nutrition.
- B. Sensory perception.
- C. pH regulation.
- D. Medication.
Correct Answer: A
Rationale: Poor nutrition (e.g., high sugar intake) is a key risk factor for diabetes, impacting metabolism. Sensory, pH, and medications are less directly causative.
Which nursing interventions are most appropriate for nursing in the health of a client with Cushing's syndrome? Select all that apply.
- A. Have the client sleep on a convoluted (egg-crate) foam mattress.
- B. Ambulate the client at frequent intervals.
- C. Advise the client to ask for assistance when getting up.
- D. Offer high-carbohydrate nourishment.
- E. Check the client frequently for suicidal ideation.
- F. Instruct the client to wear loose-fitting clothing.
Correct Answer: A,C,E,F
Rationale: These interventions address skin breakdown, fall risk, mood changes, and comfort in Cushing's syndrome.
The nurse is collecting information about the client who underwent a transsphenoidal removal of a pituitary tumor. Which findings should indicate to the nurse that the client is experiencing DI? Select all that apply.
- A. Serum osmolality 310 mOsm/kg
- B. Weight increased 2 kg in 24 hours
- C. Experiencing an extreme thirst
- D. Urine output 4200 mL in 24 hours
- E. BP averaging 164/92 mm Hg or higher
Correct Answer: A,C,D
Rationale: Elevated serum osmolality, extreme thirst, and high urine output indicate DI due to fluid loss and ADH deficiency.
The nurse is reviewing the serum laboratory report for the hospitalized client who has adrenocortical insufficiency. The nurse should immediately notify the HCP about which value?
- A. WBC 11,000/mm3
- B. Glucose 138 mg/dL
- C. Sodium 148 mEq/L
- D. Potassium 6.2 mEq/L
Correct Answer: D
Rationale: The serum potassium of 6.2 mEq/L indicates hyperkalemia, which can cause dysrhythmias and requires immediate notification.