The nurse is caring for a client with Graves' disease who has exophthalmos. The nurse should recommend that the client
Rationale:
Prevent eye dryness by applying artificial tears. Clients with exophthalmos often experience dryness and irritation due to the inability to fully close their eyes, making artificial tears essential for comfort and eye health.
B: use scanning techniques to move the head from side to side. This approach does not address the primary concern of eye dryness and does not alleviate the symptoms caused by exophthalmos.
C: take their thyroid hormone as prescribed. While thyroid hormone management is important, it does not directly alleviate the symptoms of exophthalmos or prevent dryness in the eyes.
D: sleep flat on your back without any pillows. Sleeping in this position may exacerbate eye exposure and discomfort, contrary to the need for proper eye lubrication and protection.
The nurse is caring for a client who developed a thyroid storm. The nurse should obtain a prescription for
Rationale:
Propranolol. This medication is essential in managing thyroid storm as it helps to control the excessive sympathetic activity, reducing heart rate and alleviating symptoms associated with hyperthyroidism during this critical condition.
A: enalapril. This medication is primarily used to treat hypertension and heart failure, not specifically indicated for the acute management of thyroid storm symptoms or its underlying hyperthyroidism.
B: calcium gluconate. This treatment is meant for conditions related to calcium deficiency or hypoparathyroidism, making it irrelevant in addressing the crisis presented by a thyroid storm.
C: levothyroxine. As a synthetic thyroid hormone, it would exacerbate the symptoms of hyperthyroidism during a thyroid storm rather than providing the necessary intervention for symptom control and stabilization.
The nurse is developing a plan of care for a client with hypothyroidism that is not controlled with medication. The nurse should recommend
Rationale:
Applying lotion after a warm bath. This practice helps to alleviate dry skin, a common symptom of hypothyroidism, by providing moisture and preventing skin irritation, thus enhancing the client’s comfort and care.
B: High-fiber snacks. While beneficial for digestion, these do not directly address the skin dryness associated with hypothyroidism, which is the primary concern in this scenario.
C: Caffeinated beverages to promote energy. Caffeine can lead to increased heart rate and anxiety, which are not suitable for clients with hypothyroidism, who often struggle with energy levels.
D: Physical activities with frequent rest breaks. Although exercise is important, the focus here is on skin care and comfort rather than activity levels, which does not directly address the primary concern.
E: Adding fans to the room to keep it cool. While this may provide comfort in heat, it does not specifically target the skin hydration needs that are crucial for clients with hypothyroidism.
The nurse is assessing a client with a myxedema coma. Which of the following would be an expected finding?
Rationale:
Glucose 59 mg/dL (3.28 mmol/L) is an expected finding in a myxedema coma. This condition often leads to decreased metabolism and impaired glucose regulation, resulting in hypoglycemia as observed in this case.
B: Sodium 155 mEq/L (mmol/L) indicates hypernatremia, which is uncommon in myxedema coma. Typically, patients may present with hyponatremia due to fluid retention and altered sodium handling.
C: Serum pH 7.49 signifies alkalosis, not typical in myxedema coma. This condition usually presents with a more acidic pH due to metabolic disturbances associated with severe hypothyroidism.
The following scenario applies to the next 6 items
The nurse in the clinic is caring for a 32-year-old female client.
Item 2 of 6
Nurses' Notes
1559: Client reports to the outpatient clinic with reports of persistent fatigue, weakness, lethargy, and lower back pain over the last 8 months. She is also concerned because she has gained 24 pounds (10.9 kg) over the past 4 months. She stated that the weight gain has been so significant that she developed reddened streaks on her abdomen from the weight gain. The client is concerned because, over the past month, she has noticed she has been drinking more often and has had increased hunger. She has also noticed she is urinating more frequently. She went to urgent care one week ago and tested negative for urinary tract infection. She also noticed that her menstrual cycle has been irregular. She is not on birth control and took a home pregnancy test, which was negative. During the assessment, the client was fully alert and oriented. Clear lung sounds bilaterally. Skin was dry. Excessive facial hair was noted. 1+ pedal and ankle edema bilaterally. Peripheral pulses palpable, 2+, and regular. Body mass index (BMI) of 32. Vital signs: T 97.5° F (36.4° C), P 93, RR 18, BP 145/93, pulse oximetry reading 96% on room air. She is currently taking escitalopram for persistent depressive disorder.
Laboratory Results
Capillary Blood Glucose
1613: 254 mg/dL [70-110 mg/dL]
The nurse recognizes which of the following conditions may cause a client to manifest hyperglycemia?
Rationale:
C: Pheochromocytoma can lead to hyperglycemia due to excess catecholamine production, which increases blood glucose levels by promoting glycogenolysis and gluconeogenesis. This aligns with the client's symptoms of persistent fatigue and weight gain.
A: Diabetes insipidus primarily affects water balance and does not directly elevate blood glucose levels. This condition is characterized by excessive thirst and urination, not hyperglycemia.
B: Adrenal insufficiency typically results in low cortisol levels, which can lead to hypoglycemia rather than hyperglycemia. Symptoms include fatigue and weakness, but not elevated blood sugar.
D: Hyperpituitarism can cause various hormonal imbalances, potentially affecting glucose metabolism. However, it is not a direct cause of hyperglycemia as seen in the current scenario.
E: Pancreatitis primarily affects insulin production and usually results in fluctuating glucose levels. It does not consistently lead to hyperglycemia, especially in the context of the client's symptoms.
The nurse in the clinic is caring for a 32-year-old female client.
Item 5 of 6
Nurses' Notes
1559: Client reports to the outpatient clinic with reports of persistent fatigue, weakness, lethargy, and lower back pain over the last 8 months. She is also concerned because she has gained 24 pounds (10.9 kg) over the past 4 months. She stated that the weight gain has been so significant that she developed reddened streaks on her abdomen from the weight gain. The client is concerned because, over the past month, she has noticed she has been drinking more often and has had increased hunger. She has also noticed she is urinating more frequently. She went to urgent care one week ago and tested negative for urinary tract infection. She also noticed that her menstrual cycle has been irregular. She is not on birth control and took a home pregnancy test, which was negative. During the assessment, the client was fully alert and oriented. Clear lung sounds bilaterally. Skin was dry. Excessive facial hair was noted. 1+ pedal and ankle edema bilaterally. Peripheral pulses palpable, 2+, and regular. Body mass index (BMI) of 32. Vital signs: T 97.5° F (36.4° C), P 93, RR 18, BP 145/93, pulse oximetry reading 96% on room air. She is currently taking escitalopram for persistent depressive disorder.
Laboratory Results
Capillary Blood Glucose
1613: 254 mg/dL [70-110 mg/dL]
Orders
1714:
Arrange for a follow-up appointment in 3 days
Lab orders: serum complete blood count, complete metabolic panel, hemoglobin A1C
24-hour urinary cortisol excretion
The nurse reviews the physician's orders. The nurse educates the client about the ordered 24-hour urinary cortisol excretion. Which of the following information should the nurse include?
Rationale:
You will need to begin this test by discarding your first urine specimen. Discarding the first urine sample eliminates the possibility of contamination and ensures an accurate measurement of cortisol levels throughout the 24-hour collection period, which is essential for diagnosing conditions like Cushing's syndrome or adrenal insufficiency.
C: During the urine collection, only save specimens larger than 30 mL. All urine specimens must be collected regardless of volume to ensure comprehensive analysis and accurate cortisol measurement.
F: You will need to increase your daily fluid intake to 3 liters during this test. Increasing fluid intake is unnecessary; normal hydration is recommended to avoid dilution of the urine sample, which could affect cortisol levels.
E: The urine specimen should be kept on ice or refrigerated. Proper storage is crucial, but the instructions specifically emphasize discarding the first specimen rather than focusing solely on storage conditions.
G: Collect and retain all urinary specimens during the 24-hour period. While all specimens should be collected, the initial specimen must be discarded, making this option misleading.
The nurse is reviewing endocrine disorders with a group of students. It would be correct for the nurse to identify which manifestation is associated with hyperthyroidism?
Rationale:
Insomnia. Hyperthyroidism stimulates metabolism and increases energy levels, often leading to difficulties in sleep, resulting in insomnia as a prominent manifestation associated with this condition.
A: Injected (red) conjunctiva. While hyperthyroidism can affect the eyes, injected conjunctiva specifically relates to other conditions, such as allergies or infections, rather than being a hallmark of hyperthyroidism itself.
C: Increased systolic blood pressure. Although hyperthyroidism can elevate blood pressure, the primary manifestation linked to this condition is not directly related to blood pressure changes but rather metabolic and psychological effects.
D: Diaphoresis. Excessive sweating can occur in hyperthyroidism, but it is not as definitive as insomnia, which is a more common and distinguishing feature of the disorder.
E: Confusion. While cognitive issues may arise, confusion is not a primary manifestation of hyperthyroidism, which typically presents with more pronounced symptoms related to energy and metabolism.
The following scenario applies to the next 1 items
The home health nurse visits a client with chronic diabetes insipidus
Item 1 of 1
Nurses’ Note
1415 – Home health visit completed because the client was admitted to the hospital twice in the past six weeks for treatment nonadherence related to diabetes insipidus. Extensive teaching provided and reviewed education on prescribed desmopressin intranasal, maintenance of fluids, daily weight, intake and output, and when to seek emergency care.
Which client statements would indicate a correct understanding of the teaching?
Rationale:
I will need to weigh myself at the same time every day. This statement reflects an understanding of the importance of consistent daily weight monitoring to manage diabetes insipidus effectively, as fluctuations can indicate issues with fluid balance and treatment adherence.
A: I should limit the amount of fluids that I drink after 5:00 PM. This statement misunderstands fluid management, as appropriate fluid intake is crucial throughout the day for diabetes insipidus patients.
C: I should put both doses of the desmopressin in one nostril. This approach is incorrect; desmopressin should be administered as directed, typically in separate nostrils to ensure proper absorption.
E: I may need an additional dose if I keep urinating a lot. While monitoring is vital, this statement lacks clarity; additional doses should only be taken upon medical advice, not based solely on symptoms.
F: If I develop confusion with this medication, I should call 911. Confusion can indicate a serious side effect, but contacting a healthcare provider first is more appropriate than emergency services for medication-related concerns.
The nurse is teaching a new group of nurses about insulin administration for a client with type I diabetes mellitus. Which of the following points should be included?
Rationale:
Administer insulin subcutaneously, not intramuscularly. This method ensures proper absorption and minimizes the risk of complications associated with intramuscular administration, which can lead to erratic blood glucose levels in patients with type I diabetes.
B: Regular insulin can be administered intravenously in emergency situations. While intravenous administration is possible, it is not the primary teaching point for general insulin administration practices in daily management.
C: Rotate injection sites to prevent lipohypertrophy. Although important for preventing complications, the primary focus of the teaching should be on the correct route of administration.
D: Long-acting insulin should not be mixed in the same syringe with other types of insulin. This statement is relevant but does not address the foundational teaching on administration routes for insulin.
E: It's safe to administer cold insulin directly from the refrigerator. Insulin should be at room temperature for better absorption, making this statement misleading regarding optimal administration practices.
The nurse is caring for a client who has adrenal insufficiency (Addison's disease). Which of the following interventions would be a priority?
Rationale:
Administer prescribed hydrocortisone. This intervention is critical in managing adrenal insufficiency since hydrocortisone replaces the deficient cortisol, addressing the hormonal imbalance and preventing potential adrenal crisis in the client.
B: Offer salty snacks and water. While increasing sodium intake can benefit clients, it does not address the immediate hormonal deficiency or the urgent need for cortisol replacement therapy.
C: Assess skin integrity. Although monitoring skin condition is important, it does not directly impact the acute management of adrenal insufficiency and can be prioritized after addressing hormonal needs.
D: Encourage frequent rest periods. While rest is beneficial for overall health, it does not provide the necessary treatment for the hormonal imbalance present in adrenal insufficiency, making it a lower priority.
The nurse is evaluating the treatment plan for a client with type II diabetes mellitus. Select the findings in the nurses' note that indicate that the client is not meeting the treatment goals
Rationale:
The most recent hemoglobin A1C was 7.6%. Elevated A1C levels indicate suboptimal blood glucose control, suggesting that the treatment plan is not effectively managing the client's diabetes, thus failing to meet established targets.
A: The client presents for a routine follow-up after being diagnosed with diabetes mellitus type II. This suggests ongoing management rather than a failure to meet treatment goals.
E: The client stated he stopped walking barefoot. This indicates a positive behavior change, as avoiding barefoot walking reduces the risk of foot injuries and complications related to diabetes.
F: The client requested a referral for a diabetic cooking class. This demonstrates proactive engagement in diabetes management, reflecting a willingness to learn and improve dietary habits, thus not indicating unmet treatment goals.
The nurse is educating a diabetic client regarding foot care. Which of the following statements by the client indicates a correct understanding of the nurse's instructions?
Rationale:
I need to check my feet daily for sores, blisters, dry skin, and cuts. Regular foot inspections are vital for diabetic clients, as they help identify potential issues early, reducing the risk of complications and promoting overall foot health.
B: I need to wash my feet daily and keep them dry. While cleanliness is essential, this statement alone does not address the importance of regular inspections for potential issues.
D: I need to apply cream to my heels and between my toes daily. Applying cream may prevent dryness, but it does not encompass the critical practice of daily foot assessments.
E: I should wear tight compression socks on both feet. Compression socks can impede circulation, especially if too tight, making them unsuitable for diabetic clients who may have vascular concerns.
The following scenario applies to the next 1 items.
The nurse is caring for a client in the emergency department (ED) with an altered level of consciousness
Item 1 of 1
History and Physical
A 53-year-old male presented to the emergency department (ED) with his wife because the client had become quite tired over the past several days. Today, he was difficult to arouse and spoke incoherently. The client responded to his name during the assessment but did not answer any other questions. Peripheral pulses were thready. Obvious tenting was noted in the skin, which was warm and quite dry. No facial drooping was observed, and when asked to hold out his arms, he could not perform the task. In fact, he did not have many purposeful movements during the exam. The client has a medical history of gout, bipolar disorder, and hypothyroidism, for which he takes levothyroxine, allopurinol, and quetiapine. She reports that he has been taking his medications as prescribed. However, she noted he was recently placed on Prednisone 20 mg PO BID for a gout flare. He self-discontinued the drug after taking it for two weeks and feeling better, and he did not taper as directed.
Vital Signs
Temperature 98.0° F (37° C)
Pulse 121/minute
Respirations 16/minute
Blood Pressure 90/60 mm Hg
Pulse oximetry 95% on room air
Diagnostics
12-lead electrocardiogram: sinus tachycardia with peaked T waves
Complete the sentence below by dragging one (1) condition and one (1) assessment finding. The client is at highest risk for............. related to the client's...........
Rationale:
The client is at highest risk for adrenal crisis related to the cessation of prednisone.
Adrenal crisis can occur due to abrupt withdrawal from corticosteroids like prednisone, especially after a prolonged course. The client's recent self-discontinuation of the medication without tapering increases the likelihood of adrenal insufficiency, which can explain his altered consciousness and other physical symptoms noted during the assessment.
A: myxedema coma This condition relates to severe hypothyroidism, which is not suggested in the current assessment findings and does not align with the abrupt cessation of medication.
B: catatonia This diagnosis pertains primarily to severe psychiatric disorders and is not indicated by the physical symptoms or history presented in this scenario.
E: lack of purposeful movement This finding indicates a neurological issue but does not directly correlate with the risk associated with steroid withdrawal or adrenal crisis.
F: history of hypothyroidism A history of hypothyroidism is relevant but does not specifically indicate the acute risk associated with stopping prednisone abruptly.
The nurse is caring for a client with type 1 diabetes mellitus who develops hyperglycemia between 5:00 and 6:00 AM as a result of the nighttime release of growth hormone. The nurse should recognize that this condition is consistent with
Rationale:
The dawn phenomenon. This condition is characterized by elevated blood glucose levels in the early morning due to the natural increase in insulin resistance and the secretion of growth hormone overnight.
B: Somogyi effect. This phenomenon involves rebound hyperglycemia following nocturnal hypoglycemia, not a direct response to growth hormone, which distinguishes it from the dawn phenomenon.
C: hyperosmolar hyperglycemic syndrome (HHS). HHS is a severe complication of diabetes marked by extreme hyperglycemia and dehydration, typically occurring in older adults, unrelated to early morning hormonal fluctuations.
D: diabetic ketoacidosis (DKA). DKA arises from insulin deficiency leading to ketone production and acidosis, rather than a natural hormonal rise in the early morning, thus not applicable here.
The nurse is caring for a client suspected of having an endocrine disorder. Based on the client's laboratory data, the nurse is at the highest risk for which condition? See the exhibit.
Rationale:
Cushing's syndrome/disease is the condition the nurse is at the highest risk for based on the client's laboratory data. Elevated cortisol levels indicated in the lab results suggest hypercortisolism, characteristic of Cushing's, leading to significant physiological changes and increased health concerns for the patient.
A: syndrome of inappropriate antidiuretic hormone (SIADH) Elevated antidiuretic hormone levels are not primarily indicated by the data, making it less relevant to the client's current health risks.
B: diabetes insipidus (DI) The laboratory findings do not suggest a deficiency in antidiuretic hormone or an inability to concentrate urine, which are essential for diagnosing diabetes insipidus.
D: adrenal insufficiency The data indicates heightened cortisol levels rather than a deficiency, which is crucial for diagnosing adrenal insufficiency, making this option less likely.
The nurse is attending to a client with recent, significant weight gain. Which of the following diseases decreases the basal metabolic rate?
Rationale:
Hypothyroidism decreases the basal metabolic rate, leading to weight gain due to reduced energy expenditure. In this condition, the thyroid hormone levels are low, causing slower metabolism and subsequent weight accumulation.
A: Cancer Heightened metabolic demands and energy expenditure often accompany cancer, resulting in weight loss rather than gain, which contrasts with the effects seen in hypothyroidism.
C: Chronic obstructive pulmonary disease (COPD) Typically causes weight loss due to increased energy expenditure from labored breathing, opposing the weight gain associated with decreased metabolic rates found in hypothyroidism.
D: Cardiac failure Can lead to weight gain through fluid retention but does not directly affect the basal metabolic rate, making it distinct from the metabolic slowdown seen in hypothyroidism.
The nurse is planning a staff education program about conditions that increase cortisol levels. Which of the following conditions should the nurse include?
Rationale:
Cushing's disease is a condition that significantly elevates cortisol levels due to excessive production of adrenocorticotropic hormone (ACTH), leading to adrenal gland overactivity. Including this condition in the education program is essential for understanding cortisol dysregulation.
A: Addison's disease This condition features insufficient cortisol production, leading to low levels rather than increased cortisol, making it irrelevant for the program's focus on elevated cortisol conditions.
B: Congestive heart failure (CHF) While CHF can affect stress responses, it does not directly cause elevated cortisol levels, making it an unsuitable choice for the planned educational content.
C: Renal failure Although renal failure can influence various hormonal balances, it does not specifically lead to increased cortisol levels, hence it doesn’t align with the program's objective.
The nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving an infusion of regular insulin. Which of the following clinical data should be reported to the primary healthcare provider (PHCP) immediately?
Rationale:
Potassium 3.2 mEq/L, 3.2 mmol/L (3.5-5 mEq/L, 3.5-5.1 mmol/L) should be reported to the primary healthcare provider immediately.
This value indicates hypokalemia, which can lead to serious cardiac complications, especially in clients receiving insulin therapy. Insulin drives potassium into cells, further decreasing serum levels and heightening the risk of arrhythmias, necessitating prompt medical intervention.
A: Glucose 297 mg/dL, 16.52 mmol/L (70-110 mg/dL, 4.0-11.0 mmol/L) reflects hyperglycemia typical in DKA and, while concerning, does not require immediate reporting like the potassium level does.
C: BUN 24 mg/dL, 8.568 mmol/L (10-20 mg/dL, 2.5 to 6.4 mmol/L) indicates mild renal impairment but is a common finding in DKA; it does not necessitate urgent action.
D: Hemoglobin A1C 8.9% (<7%, 4.8%-6.0%) shows long-term glucose control issues but is not an acute parameter requiring immediate communication with the healthcare provider during a DKA episode.
The nurse is discussing the functions of the parathyroid hormone (PTH) with a student. Which of the following statements would be correct for the nurse to make? The parathyroid hormone
Rationale:
Parathyroid hormone moves calcium from bones to the bloodstream. This function is vital for maintaining calcium homeostasis in the body, as PTH acts to increase serum calcium levels when they drop too low.
C: controls bodily functions such as metabolism and heart rate. This statement inaccurately attributes metabolic regulation and heart function to PTH, which primarily focuses on calcium and phosphorus balance.
D: promotes renal tubular reabsorption of phosphorus. PTH mainly influences calcium metabolism and reduces phosphorus reabsorption, making this statement fundamentally misrepresentative of its actual physiological role.
E: causes the retention of sodium and the excretion of potassium. This statement confuses PTH's function, as it does not regulate sodium or potassium levels directly; its primary role centers on calcium and phosphorus.
The nurse is performing a physical assessment on a client with Cushing's disease. Which assessment findings should the nurse expect?
Rationale:
B, C, D, E. These findings are characteristic of Cushing's disease, a condition resulting from excess cortisol, leading to symptoms like hirsutism, buffalo hump, and truncal obesity due to abnormal fat distribution. Acne may also occur as a result of hormonal changes associated with this endocrine disorder, highlighting the significant impact of cortisol on the body.
A: Hypotension. Cushing's disease typically causes hypertension due to cortisol's effects on fluid retention and blood vessel constriction, contradicting the expected finding of hypotension in this scenario.
The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) is caring for a 38-year-old client being treated for diabetic ketoacidosis (DKA).
Item 1 of 1
Nurses' Notes
0700 - Handoff report received. On assessment, the client’s breathing appears regular without any distress, and clear lung sounds are noted in all lung fields. Skin is warm to the touch and pink in tone; pulses 2+ and regular. Capillary refill is 3 seconds. Client is alert and oriented to person, place, and time. Two peripheral venous access devices (VAD) were noted in the right and left antecubital spaces. The right VAD had 0.9% saline infusing at 100 mL/hr, and the left had regular insulin infusing at 4 units/hr.
Physician Orders
• Continuous infusion of regular insulin per DKA protocol
• 0.9% saline at 100 mL/hr
• Basic metabolic panel (BMP) every 3 hours
• Obtain capillary blood glucose hourly
• Daily complete blood counts (CBC)
The nurse reviews the physician's orders and plans care. Complete the sentences below from the list of options. The nurse understands that the.....needs to be monitored due to the client's risk for..............
Rationale:
The nurse understands that the basic metabolic panel needs to be monitored due to the client's risk for hypokalemia. Monitoring the BMP is crucial in DKA management, as insulin therapy can lead to potassium shifts, increasing the risk of hypokalemia and its associated complications, making it essential for the nurse to closely observe these levels.
A: complete blood count Monitoring the CBC is important but not directly related to the risks associated with DKA management, particularly concerning electrolyte imbalances and glucose levels.
C: capillary blood glucose Monitoring capillary blood glucose is essential in DKA, yet it focuses on hyperglycemia rather than the electrolyte imbalances, specifically hypokalemia, that may arise during treatment.
D: hyperglycemia Although hyperglycemia is a significant concern in DKA, the primary focus here is on monitoring the BMP due to the specific risk of hypokalemia stemming from treatment.
F: hemoconcentration Hemoconcentration is a potential concern in dehydration and DKA; however, the priority in this context is monitoring electrolyte levels, particularly potassium, through the BMP.
The nurse administers a combination of regular insulin and NPH insulin subcutaneously to a client at 0800. At which time should the nurse initially assess the client for hypoglycemia based on the peaks of the medications?
Rationale:
B: The nurse should initially assess the client for hypoglycemia at 1000, as regular insulin peaks approximately 2 to 4 hours after administration, while NPH insulin peaks at 4 to 6 hours.
A: 830 Regular insulin reaches its peak later, meaning assessment at this time would be premature for hypoglycemia symptoms.
C: 1200 NPH insulin peaks around this time, but the initial assessment should occur earlier to catch potential hypoglycemia from the regular insulin.
D: 1400 By this time, the regular insulin would likely have already peaked, making it too late for the initial hypoglycemia assessment related to the administration.
The nurse caring for a diabetes mellitus client obtained a scheduled capillary blood glucose. The result indicated 40 mg/dL (2.22 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The client reports no symptoms. The initial action of the nurse should be which of the following?
Rationale:
B: Repeat the capillary blood glucose test to validate the result.
Confirming the initial low blood glucose reading is crucial before taking further action, especially since the client reports no symptoms of hypoglycemia, which may affect the interpretation of the results.
A: Document the finding in the medical record.
Documentation is important but does not address the immediate need to verify the accuracy of the capillary blood glucose result before proceeding with potential interventions.
C: Administer 15 grams of a quick-acting carbohydrate.
This action assumes the client is hypoglycemic, but the absence of symptoms and the need for verification makes this step premature and potentially unnecessary.
D: Administer 1 mg of glucagon subcutaneously.
Administering glucagon is suitable for severe hypoglycemia, but the client shows no symptoms, and confirmation of the blood glucose level is necessary before any treatment.
The nurse is caring for a client diagnosed with hyperparathyroidism. Which laboratory data would support this diagnosis?
Rationale:
Calcium 11.2 mg/dL (2.8 mmol/L) indicates hyperparathyroidism, as elevated calcium levels are characteristic of this condition. In hyperparathyroidism, the parathyroid hormone increases calcium levels by promoting bone resorption, renal absorption, and intestinal absorption.
A: Potassium 4.1 mEq/L (mmol/L) falls within the normal range and does not specifically indicate hyperparathyroidism, which primarily involves calcium and phosphorus levels.
B: Phosphorus 4.9 mEq/L (mmol/L) is elevated but does not directly confirm hyperparathyroidism, as the condition usually presents with low phosphorus levels due to increased renal excretion.
D: Sodium 132 mEq/L (mmol/L) indicates hyponatremia, which is unrelated to hyperparathyroidism. Sodium levels do not provide diagnostic support for parathyroid hormone activity or calcium metabolism.
The nurse is caring for a client who has nephrogenic diabetes insipidus. Which of the following medications should the nurse expect to be prescribed for the client?
Rationale:
Hydrochlorothiazide should be prescribed for the client with nephrogenic diabetes insipidus. This medication helps reduce urine output by promoting sodium and water reabsorption in the kidneys, which can alleviate symptoms associated with this condition.
A: prednisone This corticosteroid does not address the underlying issue of nephrogenic diabetes insipidus and may even exacerbate fluid retention problems in some patients.
C: verapamil This calcium channel blocker is primarily used for cardiovascular issues and has no direct effect on managing nephrogenic diabetes insipidus or its symptoms.
D: lithium This medication is often linked to causing nephrogenic diabetes insipidus rather than treating it, making it unsuitable for managing the client's condition effectively.
The nurse is caring for a client who has acute pancreatitis. Based on the 11:15 AM vital signs, the nurse should prioritize which action? Click to view the exhibit for additional client information.
Rationale:
Assess the client for pain.
Prioritizing pain assessment in a client with acute pancreatitis is crucial, as unmanaged pain can lead to complications and impact overall recovery. Understanding the client's pain level helps guide further interventions and medication administration effectively, ensuring the client’s comfort and stability.
A: Obtain a 12-lead electrocardiogram. While cardiac monitoring may be necessary in certain situations, immediate pain assessment is paramount for managing acute pancreatitis symptoms.
C: Apply oxygen via nasal cannula. Administering oxygen may be beneficial, but addressing the client's pain is essential for providing comprehensive care in acute pancreatitis scenarios.
D: Infuse 500 ml 0.9% sodium chloride (normal saline) bolus. Fluid resuscitation is important, yet evaluating the client's pain takes precedence to ensure adequate management of acute pancreatitis symptoms.
The nurse is caring for a client with Addison's disease. Which statement, if made by the client, would require follow-up?
Rationale:
The client joined a gym to train for an upcoming marathon. This statement requires follow-up due to the increased physical stress and potential risk of adrenal crisis associated with strenuous exercise in Addison's disease.
A: I started using table salt instead of salt substitutes. This choice indicates an understanding of the need for increased sodium intake, which is important for managing Addison's disease effectively.
C: I recently started wearing a MedicAlert bracelet. This action demonstrates a proactive approach to alerting healthcare providers about the client’s condition, ensuring safety in emergencies related to Addison's disease.
D: If I start to feel ill, I should call my doctor right away. This statement reflects appropriate awareness and readiness to seek medical advice, indicating responsible management of the client’s health condition.
The nurse should............ because...........
Rationale:
The nurse should obtain an order to change the intravenous fluids (IV) because the client's glucose level warrants a change in IV fluids.
Obtaining an order to change IV fluids is appropriate when the glucose level indicates that current management is insufficient, ensuring patient safety and effective treatment. Adjusting IV fluids helps to stabilize glucose levels and prevent complications related to hyperglycemia or hypoglycemia.
B: pause the regular insulin infusion. Halting insulin could exacerbate hyperglycemia, especially if the glucose levels require active management through the appropriate IV fluids rather than stopping the infusion.
C: continue the regular insulin infusion. Maintaining the insulin infusion without adjusting IV fluids risks inadequate glucose control, as the patient’s current condition necessitates a reevaluation of fluid therapy.
E: the client's glucose level is dropping too fast. Rapid declines in glucose levels typically necessitate careful monitoring rather than immediate alterations to IV fluids, which could lead to further instability.
F: the glucose level is dropping at a therapeutic level. A therapeutic drop in glucose does not warrant changing IV fluids; instead, it suggests that current management is effectively stabilizing the patient’s condition.
The following scenario applies to the next 1 items
The nurse in the emergency department cares for a 45-year-old female
Nurses’ Note
The client reports significant fatigue that has worsened over the past eight weeks. Additionally, the client reports constipation, hair loss, and a 3-kilogram (6.6 pounds) weight gain. She reports missing work because of difficulty concentrating and persistent fatigue.
The client is alert and fully oriented. She appears fatigued and reports dizziness when she moves quickly. Periorbital edema, various bruises, and facial swelling were noted on assessment. Peripheral pulses were intact and weak. The client denies any pain.
Vital Signs
Oral temperature 97 F (36.1o C); Pulse 51/minute; Respirations 15/minute.
BP 93/61 mm Hg; Oxygen saturation 95% on room air.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Obtain a prescription for levothyroxine, Obtain a prescription for methimazole, Have the client complete a blood transfusion consent, Obtain an order for a urine cortisol level, Initiate fall precautions.
B
Vital Signs, Serum TSH/T3/T4 levels, Intake and Output, Cortisol Level, BUN and Creatinine.
C
Graves' disease, Cushing's syndrome, Hypothyroidism, Systemic Lupus Erythematosus, Adrenal Insufficiency.
Rationale:
Hypothyroidism. This condition is characterized by symptoms such as fatigue, weight gain, hair loss, and bradycardia, which align with the client's reported experiences and assessment findings of low heart rate and edema.
A: Obtain a prescription for levothyroxine. This action is suitable for treating hypothyroidism, but methimazole is for hyperthyroidism, which is not applicable in this scenario.
B: Vital Signs. While monitoring vital signs is essential, assessing thyroid hormone levels provides more specific insight into the underlying cause of the client’s symptoms.
C: Graves' disease. This condition leads to hyperthyroidism, presenting with opposite symptoms such as weight loss and increased heart rate, contrasting sharply with the client's clinical presentation of fatigue and bradycardia.
D: Systemic Lupus Erythematosus. This autoimmune disorder can cause fatigue, but the specific combination of symptoms indicates hypothyroidism rather than lupus, which presents differently.
E: Adrenal Insufficiency. Although it can cause fatigue, the specific symptoms noted, including weight gain and severe bradycardia, are more indicative of hypothyroidism than adrenal insufficiency.
The nurse is reviewing data for a client who is establishing primary care. Select the findings from the history and physical that are risk factors for diabetes mellitus (type two).
Rationale:
High blood pressure and high cholesterol are significant risk factors for type two diabetes, as they are often associated with metabolic syndrome and insulin resistance. A body mass index of 28 also indicates overweight status, contributing to the likelihood of developing diabetes.
A: The client has a medical history of testicular cancer that was treated when he was 24. This specific cancer history does not directly relate to diabetes risk factors or metabolic health.
C: two years ago but never followed up with treatment. Lack of follow-up treatment does not specify any direct correlation with diabetes risk factors in the current health assessment.
E: He drinks one glass of red wine three times a week and stopped smoking cigarettes one year ago. Moderate alcohol consumption and cessation of smoking are not recognized risk factors for diabetes mellitus in this context.
The nurse is assessing a client with diabetic ketoacidosis (DKA). Which of the following would be an expected finding?
Rationale:
Tachycardia is an expected finding in a client with diabetic ketoacidosis (DKA). This response occurs due to dehydration and electrolyte imbalances, stimulating the heart rate as the body attempts to maintain adequate perfusion and oxygenation during metabolic distress.
A: Thready pulse indicates a weak and irregular heartbeat, typically associated with severe hypotension or shock rather than DKA alone.
B: Jugular venous distention (JVD) suggests fluid overload or heart failure, conditions not typically present in DKA, which often involves dehydration.
C: Coarse tremors are typically linked to hypoglycemia or neurological issues, not specifically a hallmark sign of diabetic ketoacidosis, which presents differently.
E: Orthostatic hypotension occurs due to dehydration and is not as directly linked to the primary physiological response seen in DKA, which primarily features tachycardia.
The nurse is caring for a client who recently had a dosage increase of prescribed levothyroxine. Which of the assessments following the increase is a priority?
Rationale:
B: Heart rate monitoring is crucial after a levothyroxine dosage increase, as it can lead to hyperthyroid symptoms, including tachycardia. Assessing heart rate helps identify potential adverse effects and necessary interventions early.
A: Weight assessment can indicate metabolic changes, but it is not as immediately critical as heart rate in detecting potential complications from increased levothyroxine.
C: Activity status is relevant for evaluating overall well-being, yet it does not provide immediate insights into the cardiovascular impact of the medication change following a dosage increase.
D: Oral temperature offers some information about metabolic activity but is less specific for detecting heart-related issues that could arise from elevated levothyroxine levels, making it a lower priority.
The nurse is teaching a client who is receiving newly oral prednisone. Which of the following Information should the nurse include concerning the possible side effects of this medication?
Rationale:
Increased susceptibility to infection. Prednisone suppresses the immune system, making it more challenging for the body to fend off infections, thereby increasing the client's risk of becoming ill while on this medication.
B: Weight gain. Prednisone can lead to fluid retention and increased appetite, contributing to weight gain, but this is a secondary effect rather than a direct consequence of immune suppression.
C: Insomnia. While prednisone can affect sleep patterns due to its stimulating effects, insomnia is not primarily linked to the immune suppression aspect of the drug.
D: Blood glucose elevation. Prednisone can elevate blood sugar levels; however, this side effect is more related to metabolic changes rather than directly impacting immune function or susceptibility to infections.
The nurse is caring for a client who is receiving newly prescribed prednisone. Which of the following medications should the client avoid while receiving this medication?
Rationale:
Avoiding naproxen is crucial while on prednisone due to the increased risk of gastrointestinal bleeding and ulcers. Prednisone can weaken the stomach lining, and naproxen is a nonsteroidal anti-inflammatory drug that can exacerbate this risk, leading to potentially severe complications.
A: valsartan Valsartan does not pose significant risks when combined with prednisone, as it primarily manages hypertension and does not affect gastrointestinal integrity.
C: omeprazole Omeprazole is a proton pump inhibitor that protects the stomach, actually helping counteract potential side effects of prednisone rather than causing harm or complications.
D: acetaminophen Acetaminophen is generally safe with prednisone, offering pain relief without the gastrointestinal risks associated with NSAIDs like naproxen, making it a suitable option for managing discomfort.
The nurse is teaching a client about storing their prescribed insulin. Which statement, if made by the client, would indicate a correct understanding of the teaching?
Rationale:
Unopened vials of insulin should be stored in the refrigerator. Proper refrigeration helps maintain insulin's efficacy and stability, preventing degradation and ensuring it remains effective for managing blood glucose levels over time.
A: Opened vials of insulin may be kept in the freezer. Freezing insulin can cause it to become ineffective, compromising its therapeutic benefits and potentially resulting in poor glycemic control.
B: My opened vial of insulin is good for 45 days. Opened vials of insulin are typically effective for 28 days, and exceeding this timeframe can lead to reduced potency and effectiveness.
C: If I travel, I can keep a vial of insulin in my car. High temperatures in a car can damage insulin, leading to decreased efficacy and unsafe blood sugar management during travel.
The nurse is teaching a client prescribed prednisolone. Which of the following information should the nurse include?
Rationale:
Take this medication in the morning with food.
Taking prednisolone in the morning aligns with the body's natural cortisol rhythm, reducing potential side effects and enhancing absorption when taken with food, which helps minimize gastrointestinal irritation.
B: The best time to take this medication is later in the afternoon without food. Administering prednisolone later may disrupt sleep patterns and increase gastrointestinal discomfort due to the lack of food.
C: This medication before bed with a light snack. Taking prednisolone before bed can interfere with sleep and increase the risk of side effects, making it an unsuitable timing choice.
D: You can take this medication anytime, as long as you take it on an empty stomach. Flexibility in timing may lead to inconsistent blood levels and increased risk of side effects, undermining treatment efficacy.
This nurse is caring for a client who is receiving prescribed sitagliptin. The nurse understands that this medication is intended to treat which condition?
Rationale:
Diabetes mellitus. Sitagliptin is specifically designed to manage blood glucose levels in individuals diagnosed with type 2 diabetes, enhancing insulin secretion and lowering blood sugar levels effectively.
A: Hyperlipidemia Sitagliptin does not address lipid levels or cholesterol management, focusing solely on glycemic control in diabetic patients rather than influencing lipid metabolism.
C: Hypothyroidism This medication has no role in treating thyroid disorders, as its mechanism and effects are exclusively targeted towards regulating blood sugar levels.
D: Hypertension Sitagliptin does not influence blood pressure regulation; it is primarily aimed at controlling diabetes-related complications rather than cardiovascular conditions.
A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider?
Rationale:
Decreased glomerular filtration rate (GFR) should be reported to the provider. Metformin is contraindicated in patients with reduced kidney function, as it increases the risk of lactic acidosis, making monitoring GFR crucial for patient safety.
A: Decreased blood urea nitrogen (BUN) level does not indicate a need for concern, as it may reflect improved kidney function or hydration status unrelated to metformin therapy.
C: Decreased fasting plasma glucose signifies effective diabetes management, indicating that the medication is working as intended, and does not warrant immediate communication with the provider.
D: Decreased hemoglobin A1C demonstrates good long-term glucose control, suggesting the treatment is effective and does not necessitate any urgent reporting to the healthcare provider.
The nurse is caring for a client with a prescribed subcutaneous (SQ) regular insulin sliding scale. The client's current blood glucose level is 360 mg/dL (19.98 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. Which of the following actions should the nurse take? See the exhibit.
Rationale:
Administer 8 units of regular insulin. This option aligns with the sliding scale protocol, which dictates the appropriate insulin dosage based on the client's elevated blood glucose level of 360 mg/dL.
C: Administer 10 units of regular insulin. This dosage exceeds the calculated requirement for a blood glucose level of 360 mg/dL, risking hypoglycemia.
D: Recheck the client's blood glucose in one hour. Waiting to recheck may delay necessary insulin administration, potentially leading to further complications from hyperglycemia.
E: Administer the insulin intravenous (IV) push. Subcutaneous insulin is indicated in this scenario; IV administration is inappropriate and not standard for managing sliding scale insulin therapy.
The nurse has instructed a client scheduled for an injection of dulaglutide for diabetes mellitus (type two). Which of the following statements by the client would require follow-up?
Rationale:
Clients should not take dulaglutide immediately before or after a meal, as it is designed to be taken independently of meal times to optimize its effectiveness and minimize gastrointestinal side effects.
A: I should tell my doctor if I experience abdominal pain and vomiting. Reporting these symptoms is essential, as they may indicate potential adverse reactions that require medical attention.
C: If this medication works, I should notice a reduction in my hemoglobin A1C (HbA1c). A decrease in HbA1c signifies effective blood sugar management, which is a valid expectation from dulaglutide treatment.
D: I will receive this medication once a week. Dulaglutide is indeed administered weekly, aligning with the recommended dosing schedule for optimal therapeutic outcomes in managing diabetes.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
Rationale:
Hydrocortisone for a client with diabetes insipidus should be questioned by the nurse. Diabetes insipidus requires vasopressin or desmopressin, while hydrocortisone can exacerbate fluid retention and imbalance issues.
A: Furosemide for a client with hyperparathyroidism. Furosemide is often utilized to manage hypercalcemia associated with hyperparathyroidism, effectively promoting renal calcium excretion and addressing elevated calcium levels.
B: Methimazole for a client with hyperthyroidism. Methimazole is indicated for hyperthyroidism, as it inhibits thyroid hormone synthesis, helping to control excessive hormone production and mitigate symptoms of the condition.
D: Prazosin for a client with pheochromocytoma. Prazosin is beneficial in pheochromocytoma management, alleviating hypertension by blocking alpha-1 adrenergic receptors and reducing adrenergic symptoms linked to catecholamine secretion.
The nurse is teaching a client with diabetes mellitus (type two) newly prescribed rapid-acting insulin. Which of the following information should the nurse include?
Rationale:
C: You can inject yourself with this insulin while you are actively eating. Rapid-acting insulin is designed to be administered just before or during meals, providing immediate glucose control as food intake occurs, which is crucial for managing blood sugar levels in diabetes.
A: Once you open your vial of insulin, discard it 25 days after opening it. Insulin vials can typically be used for 28 days once opened, making this timeframe inaccurate.
B: Inject yourself with this insulin 20-30 minutes before meals. Rapid-acting insulin should actually be administered immediately before or at mealtime, not 20-30 minutes in advance.
D: This insulin is administered right before you go to bed to minimize overnight blood sugar spikes. Rapid-acting insulin is not intended for nighttime use; it is specifically formulated for meal-related blood sugar management.
The nurse is preparing to administer a regular insulin IV bolus to a client. The primary health care provider (PHCP) has prescribed an initial bolus dose of 0.1 unit/kg. The client weighs 242 lbs. How much regular insulin should the nurse administer to the client as an IV bolus?
Rationale:
11
To calculate the insulin dosage, convert the client's weight from pounds to kilograms: 242 lbs ÷ 2.2 = 110 kg. Multiply the weight by the prescribed dose: 110 kg × 0.1 unit/kg = 11 units of regular insulin for the IV bolus.
A: 10 A dose of 10 units is derived from inaccurate weight conversion or calculation, leading to an insufficient amount of insulin for effective treatment.
B: 12 A dose of 12 units exceeds the required calculation based on the client's weight, which could result in potential overdose and complications for the patient.
C: 9 A dose of 9 units underestimates the necessary insulin required for this client, failing to meet the prescribed therapeutic goals for their condition.
This nurse is caring for a client who is receiving prescribed sitagliptin. Which assessment findings indicate the client is experiencing a severe adverse effect?
Rationale:
Abdominal pain indicates the client is experiencing a severe adverse effect of sitagliptin, as this medication can lead to pancreatitis, which typically presents with significant abdominal discomfort and pain.
A: Nasal stuffiness This symptom is generally mild and does not indicate a severe adverse effect associated with sitagliptin, as it is more commonly linked to upper respiratory issues than to serious conditions.
C: Headache While headaches can occur as side effects, they are often mild and not indicative of severe reactions associated with sitagliptin, lacking the seriousness of abdominal pain.
D: Occasional dry cough A dry cough may result from various conditions unrelated to sitagliptin, and it typically does not signify a severe adverse effect linked to this particular medication.