Endocrine And Metabolic Disorders (Part 2)

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1. A nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

Explanation

RATIONALE: A client with diabetes mellitus should wash and inspect his feet daily and should wear nonconstrictive shoes. Corns should be treated by a podiatrist — not with commercial preparations. Nails should be filed straight across. Clients with diabetes mellitus should never walk barefoot.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1419.

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About This Quiz
Endocrine And Metabolic Disorders (Part 2) - Quiz

Endocrine and metabolic diseases span a vast range of conditions. Together, they affect many millions of Americans and can profoundly decrease the quality of life. The disorders can... see moreresult in hormone overproduction or underproduction. At the end of studying part two, take the quiz below to test what you have understood so far. All the best! see less

2. A client with type 1 diabeteshas a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating:

Explanation

RATIONALE: The nurse is providing accurate information to the client when she states that the glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting period before blood is drawn. The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin coverage.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1376.

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3. After a 3-month trial of dietary therapy, a client with type 2 diabetesstill has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take the glyburide:

Explanation

RATIONALE: Like other oral antidiabetic agents ordered in a single daily dose, glyburide should be taken with breakfast or 30 minutes before breakfast. If the client takes glyburide later, such as in mid-morning, after dinner, or at bedtime, the drug won't provide adequate coverage for all meals consumed during the day.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 576.

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4. An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, andangina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

Explanation

RATIONALE: To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. Then the client should check his blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1411.

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5. A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:

Explanation

RATIONALE: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1419.

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6. A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?

Explanation

RATIONALE: Signs and symptoms associated with hypoglycemia include nervousness, diaphoresis, weakness, light-headedness, confusion, paresthesia,irritability, headache, hunger,tachycardia, and changes in speech, hearing, or vision. If untreated, signs and symptoms may progress to unconsciousness, seizures, coma, and death.Polydipsia,polyuria, andpolyphagiaare symptoms associated withhyperglycemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1410.

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7. A client with diabetes mellitusmust learn how to self-administer insulin. The physician has ordered 10 units of U-100 regular insulin and 35 units of U-100 isophane insulinsuspension(NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

Explanation

RATIONALE: The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy(such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1407.

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8. A nurse teaches a client with newly diagnosed hypothyroidismabout the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?

Explanation

RATIONALE: Levothyroxine is the agent of choice for thyroid hormone replacement therapy because its standard hormone content provides predictable results. Methimazole is an antithyroid medication used to treat hyperthyroidism. Thyroid USP desiccated and liothyronine are no longer used for thyroid hormone replacement therapy because they may cause fluctuating plasma drug levels, increasing the risk of adverse effects.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1453.

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9. Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis?

Explanation

RATIONALE: Blood glucose needs to be monitored in clients receiving I.V. insulin because of the risk of hyperglycemiaorhypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by I.V. insulin administration.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1413.

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10. A client visits the physician's office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves' disease. Based on history and physical findings, the nurse suspectshyperthyroidism. Exophthalmos is characterized by:

Explanation

RATIONALE: Exophthalmos is characterized by protruding eyes and a fixed stare. Dry, waxy swelling and abnormal mucin deposits in the skin typify myxedema, a condition resulting from advancedhypothyroidism. A wide, staggering gait and a differential between the apical and radial pulse rates aren't specific signs of thyroid dysfunction.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1440.

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11. A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find:

Explanation

RATIONALE: Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1480.

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12. A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by:

Explanation

RATIONALE: A corticotropin-secreting pituitary adenoma is the most common cause of Cushing's syndrome in women ages 20 to 40. Ectopic corticotropin-secreting tumors are more common in older men and are commonly associated with weight loss. Adrenal carcinoma isn't usually accompanied by hirsutism. A female with an inborn error of metabolism wouldn't be menstruating.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1479.

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13. A client with a history of Addison's diseaseand flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. His wife reports that he acted confused and was extremely weak when he awoke that morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion?

Explanation

RATIONALE: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated withhypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — nothypotonic— saline solution.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1478.

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14. A client with primary diabetes insipidusis ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?

Explanation

RATIONALE: The nurse should advise the client that desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and get adequate fluid replacement.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 363.

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15. Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use?

Explanation

RATIONALE: Hb A1cis the most reliable indicator of glucose use because it reflects blood glucose levels for the prior 3 months. Although a fasting blood glucose test and a 6-hour glucose tolerance test yield information about a client's use of glucose, the results are influenced by such factors as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose use but is limited in its diagnostic significance.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1376.

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16. Which instruction about levothyroxine (Synthroid) administration should a nurse teach a client?

Explanation

RATIONALE: The nurse should instruct the client to take levothyroxine on an empty stomach (to promote regular absorption) in the morning (to help prevent insomnia and to mimic normal hormone release).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 693.

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17. Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use?

Explanation

RATIONALE: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 323.

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18. A client is diagnosed with syndrome of inappropriate antidiuretic hormone(SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

Explanation

RATIONALE: Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidusa condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 317.

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19. A nurse is preparing a client with type 1 diabetesfor discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker?

Explanation

RATIONALE: The client should be referred to a dietitian, who will help him gain better control of his blood glucose levels. The client can care for himself, so a home health agency isn't necessary. The client shows no signs of needing a psychiatric referral, and referring the client to a psychiatrist isn't in the nurse's scope of practice. Social workers help clients with financial concerns; the scenario doesn't indicate that the client has a financial concern warranting a social worker at this time.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1410.

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20. A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites?

Explanation

RATIONALE: Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1408.

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21. During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

Explanation

RATIONALE: To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1469.

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22. When referred to a podiatrist, a client newly diagnosed with diabetes mellitusasks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:

Explanation

RATIONALE: The nurse should make the client aware that diabetes affects sensation in the feet and that he might hurt his foot but not feel the wound. Although it's important that the client's shoes fit properly, this isn't the only reason the client's feet need to be checked. Telling the client that diabetes mellitus increases the risk of infectionor stating that the circulation in the client's feet indicates the severity of his diabetes doesn't provide the client with complete information.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1408.

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23. A woman with a progressively enlarging neck comes into the clinic. She mentions that she has been in a foreign country for the previous 3 months and that she didn't eat much while she was there because she didn't like the food. She also mentions that she becomes dizzy when lifting her arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose?

Explanation

RATIONALE: A goiter can result from inadequate dietary intake of iodine associated with changes in foods or malnutrition. It's caused by insufficient thyroid gland production and depletion of glandular iodine. Signs and symptoms of this malfunction include an enlarged thyroid gland, dizziness when raising the arms above the head, dysphagia, and respiratory distress. Signs and symptoms ofdiabetes mellitusincludepolydipsia,polyuria, andpolyphagia. Signs and symptoms ofdiabetes insipidusinclude extreme polyuria (4 to 16 L/day) and symptoms ofdehydration(poor tissue turgor, dry mucous membranes, constipation, dizziness, and hypotension).Cushing's syndromecauses buffalo hump, moon face, irritability, emotional lability, and pathologic fractures.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1466.

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24. A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subcutaneously. She awakens in 5 minutes. Why should her husband offer her a complex carbohydrate snack as soon as possible?

Explanation

RATIONALE: A client with type 1 diabetes who requires glucagon should be given a complex carbohydrate snack as soon as possible to restore the liver glycogen and prevent secondary hypoglycemia. A complex carbohydrate snack doesn't decrease the possibility of nausea and vomiting or stimulate the appetite, and it increases the amount of glycogen in the system.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1411.

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25. A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Explanation

RATIONALE: Lactated Ringer's solution, with an osmolalityof approximately 273 mOsm/L, isisotonic. The nurse shouldn't give half-normal saline solution because it'shypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions arehypertonic.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 311.

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26. Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the charge nurse to change her assignment. She is frustrated because she has had to devote so much time and energy to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus. The charge nurse should:

Explanation

RATIONALE: Staff members need to know the charge nurse is a supportive leader who respects their honesty and stands behind them. By offering to help with discharge teaching, the charge nurse is actively engaging with her staff at a time of need. Changing all the assignments on this extremely busy floor would be counterproductive. Insisting that the staff member follow through with her assignment disrespects her request and genuine need. Providing a float nurse could help, but there are no guarantees a float nurse is available.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 120.

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27. A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Explanation

RATIONALE: After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomyset at the client's bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't indicated for this client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1469.

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28. A nurse is caring for a client with type 1 diabeteswho exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:

Explanation

RATIONALE: This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1411.

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29. While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that she forgot to administer insulin to client with diabetes mellitus. She's made numerous errors in the past few weeks and is now afraid her job is in jeopardy. What is her best course of action?

Explanation

RATIONALE: Making an error can be very stressful and a nurse may feel great pressure to hide her mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, she must still report the error and complete the proper paperwork. The nurse should contact the physician and follow his instructions, but she shouldn't bypass proper protocol.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 966.

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30. A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect:

Explanation

RATIONALE: Graves' disease, an autoimmune disease causinghyperthyroidism, is most prevalent in middle-aged females. In Hashimoto's thyroiditis, the most common form ofhypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, radioactive iodine uptake is low (≤2%), and a client with a multinodular goiter will show an uptake in the high-normal range (3% to 10%).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1459.

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31. A female client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in:

Explanation

RATIONALE: Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism, not hair loss, is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth declines.Osteoporosisoccurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases.Amenorrheadevelops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1480.

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32. A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see?

Explanation

RATIONALE: A serum potassium level of 6.8 mEq/L indicates hyperkalemia, which can occur in adrenal insufficiency as a result of reduced aldosterone secretion. A BUN level of 2.3 mg/dl is lower than normal. A client in addisonian crisis is likely to have an increased BUN level because the glomerular filtration rate is reduced. A serum sodium level of 156 mEq/L indicates hypernatremia. Hyponatremia is more likely in this client because of reduced aldosterone secretion. A serum glucose level of 236 mg/dl indicates hyperglycemia. This client is likely to have hypoglycemia caused by reduced cortisol secretion, which impairs glyconeogenesis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1478.

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33. A client with newly diagnosed type 2 diabetesis admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into her teaching plan?

Explanation

RATIONALE: Type 2 diabetes is commonly obesity-related; therefore, weight reduction may enhance the normalization of the blood glucose level. Weight reduction should be achieved by a healthy diet and exercise to increase carbohydrate metabolism. Blood glucose levels should be maintained within normal limits to prevent the development of diabetic complications. Clients with type 1 or 2 diabetes shouldn't smoke at all because of the increased risk of cardiovascular disease. A funduscopic examination should be done yearly to identify early signs of diabetic retinopathy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1384.

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34. A client has recently undergone surgical removal of a pituitary tumor. The physician orders corticotropin (Acthar), 20 units I.M. q.i.d., as a replacement therapy. What is the mechanism of action of corticotropin?

Explanation

RATIONALE: Corticotropin interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and carbohydrate metabolism. It doesn't decrease cAMP production. Antidiuretic hormone regulates the threshold for water resorption in the kidneys.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 324.

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35. An admitting nurse on a rehabilitation unit notices that an elderly client with a fractured hip and severe hypothyroidismis dirty and disheveled and that his personal hygiene is very poor. As the nurse gathers admission data, she further notes that the client has few personal connections, is depressed, and doesn't seem to care about his appearance. How should the nurse improve the client's performance of self-care activities?

Explanation

RATIONALE: Low thyroid levels can cause depression, which can explain many of this client's symptoms. Rather than assuming the client doesn't care about his appearance, the nurse should provide supportive hygienic care and observe for mood changes as the client's thyroid levels improve. Offering to escort the client to the shower and help with his hair, providing complete hygienic care and making an appointment with the hospital barber, and asking the physician to refer the client to social services are appropriate interventions to take if the client's behavior doesn't improve as thyroid level improves.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 318.

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36. A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?

Explanation

RATIONALE: Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8 mEq/L best supports a diagnosis of Addison's disease. A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits. In a client with Addison's disease, the serum sodium level would be much lower than 134 mEq/L, a nearly normal level.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1478.

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37. A client with hypothyroidismis afraid of needles and doesn't want to have his blood drawn. What should the nurse say to help alleviate his concerns?

Explanation

RATIONALE: The nurse should tell the client that she will stay with him as the blood is drawn. This response provides the client with the reassuring presence of the nurse and enhances the therapeutic alliance, possibly providing a greater opportunity to educate the client. Although telling the client that blood won't need to be drawn as often when thyroid levels are stable provides the client with a rationale for needing blood work, it's more appropriate for the nurse to stay with the client. Saying that the procedure will be over quickly or that the physician has ordered the blood draw ignores the client's stated fear.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1458.

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38. A client with Addison's diseasecomes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:

Explanation

RATIONALE: In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1478.

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39. A client is diagnosed with syndrome of inappropriate antidiuretic hormone(SIADH). The nurse informs the client that the physician will orderdiuretictherapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

Explanation

RATIONALE: Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemicshockresults from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur.Tetanyresults from hypocalcemia, an electrolyte disturbance not associated with SIADH.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 318.

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40. A client is taking glyburide (DiaBeta), 1.25 mg P.O. daily, to treat type 2 diabetes. Which statement indicates the need for further client teaching about managing this disease?

Explanation

RATIONALE: The client requires further teaching if he states that he skips meals. A client who is receiving an oral antidiabetic agent should eat meals on a regular schedule because skipping a meal increases the risk of hypoglycemia. Carrying hard candy, avoiding exposure to the sun, and always wearing a medical identification bracelet indicate effective teaching.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1384.

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41. A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

Explanation

RATIONALE: Tetanymay result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized bytachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severehyperthyroidism— not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1470.

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42. Which instruction about insulin administration should a nurse give to a client?

Explanation

RATIONALE: The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1406.

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43. Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

Explanation

RATIONALE: Muscle weakness, bradycardia, nausea, diarrhea, andparesthesiaof the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1477.

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44. A nurse should perform which intervention for a client with Cushing's syndrome?

Explanation

RATIONALE: The nurse should explain to the client that Cushing's syndrome causes physical changes related to excessive corticosteroids. Clients with hyperthyroidism, not Cushing's syndrome, are heat intolerant and must have cool clothing and bedding. Clients with Cushing's syndrome should have a high-protein, not low-protein, diet. Clients withAddison's diseasemust increase sodium intake and fluid intake in times of stress of prevent hypotension.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1482.

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45. What is the most common cause of hyperaldosteronism?

Explanation

RATIONALE: An autonomous aldosterone-producing adenoma is the most common cause of hyperaldosteronism. Hyperplasia is the second most frequent cause. Aldosterone secretion is independent of sodium and potassium intake and pituitary stimulation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1473.

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46. When caring for a client with diabetes insipidus, the nurse expects to administer:

Explanation

RATIONALE: Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiencespolyuria. Insulin and dextrose are used to treatdiabetes mellitusand its complications, not diabetes insipidus.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1448.

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47. Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism?

Explanation

RATIONALE: Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hyperphosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1471.

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48. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 units of regular insulin. The nurse should expect the dose's:

Explanation

RATIONALE: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 to 6 p.m.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 630.

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49. A client with diabetes mellitushas a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulinsuspension(NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

Explanation

RATIONALE: Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals.Hyperglycemia, in which serum glucose level is above 180 mg/dl, causes such early manifestations as fatigue, malaise, drowsiness,polyuria, andpolydipsia. A serum calcium level of 8.9 mg/dl or 10.2 mg/dl is within normal range and wouldn't cause the client's symptoms.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1410.

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50. Parathyroid hormone (PTH) has which effects on the kidney?

Explanation

RATIONALE: PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D. PTH doesn't have a role in the metabolism of vitamin E.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1470.

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51. A client with diabetes mellitushas a foot ulcer. The physician orders bed rest, awet-to-damp dressingchange every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client?

Explanation

RATIONALE: For this client, wet-to-damp dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Dry, sterile dressings protect the wound from mechanical trauma and promote healing. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1234.

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52. A client with status asthmaticusrequiresendotracheal intubationand mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated withhypoglycemia?

Explanation

RATIONALE: Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin,bradycardia, and somnolence are signs and symptoms associated withhypothyroidism.Polyuria,polydipsia, andpolyphagiaare signs and symptoms ofdiabetes mellitus.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1410.

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53. After taking glipizide (Glucotrol) for 9 months, a client experiences secondary failure. What should the nurse expect the physician to do?

Explanation

RATIONALE: The nurse should anticipate that the physician will order a different oral antidiabetic agent. Many clients (25% to 60%) with secondary failure who take glipizide respond to a different oral antidiabetic agent. Therefore, it wouldn't be appropriate to initiate insulin therapy at this time. However, if a new oral antidiabetic agent is unsuccessful in keeping glucose levels at an acceptable level, insulin may be used in addition to the antidiabetic agent. Restricting carbohydrate intake isn't necessary.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1398.

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54. An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement aboutdiabetes mellitusis true?

Explanation

RATIONALE: Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Only about one-third of clients with diabetes mellitus are older than age 60 and 85% to 90% have type 2. At least 80% of clients diagnosed with type 2 diabetes mellitus are obese.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1379.

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55. A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis ofIneffective coping related to diabetes mellitus?

Explanation

RATIONALE: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen.Skipping insulin doses during illness would support a nursing diagnosis ofDeficient knowledge related to treatment of diabetes mellitus.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1417.

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56. A client with type 1 diabetestakes 15 units of Humulin N insulin before breakfast and 8 units before dinner. During a follow-up visit, the nurse reevaluates the client's knowledge about insulin therapy and self-administration skills. The nurse realizes the client requires additional teaching when she discovers the client takes which over-the-counter preparations?

Explanation

RATIONALE: The client requires additional teaching if he takes salicylates with insulin. Salicylates may interact with insulin, causing hypoglycemia. Antacids, vitamins with iron, and acetaminophen aren't known to interact with insulin.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 632.

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57. Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone(SIADH) secretion is experiencing complications?

Explanation

RATIONALE: SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 318.

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58. A nurse should expect a client with hypothyroidismto report:

Explanation

RATIONALE: Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms ofhyperthyroidism(Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1454.

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59. Before undergoing a subtotal thyroidectomy, a client receives potassium iodide (Lugol's solution) and propylthiouracil (PTU). The nurse should expect the client's symptoms to subside:

Explanation

RATIONALE: Potassium iodide reduces the vascularity of the thyroid gland and is used to prepare the gland for surgery. Potassium iodide reaches its maximum effect in 1 to 2 weeks. PTU blocks the conversion of thyroxine to triiodothyronine, the more biologically active thyroid hormone. PTU effects are also seen in 1 to 2 weeks. To relieve symptoms of hyperthyroidismin the interim, clients are usually given abeta-adrenergic blockersuch as propranolol (Inderal).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1462.

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60. A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?

Explanation

RATIONALE: Weight loss, nervousness, and tachycardiaare signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation,lethargy, decreased sweating, and cold intolerance are signs ofhypothyroidism.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1459.

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61. A nurse is teaching a client about glipizide (Glucotrol) therapy. The nurse warns the client that glipizide commonly causes hypoglycemiawhen combined with which over-the-counter preparation?

Explanation

RATIONALE: When taken in combination with aspirin, glipizide commonly causes hypoglycemia. Acetaminophen, St. John's Wort, and multivitamins may be taken with glipizide without increasing the risk of hypoglycemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 573.

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62. A nurse should expect to administer which medication to a client with gout?

Explanation

RATIONALE: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, adiuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps, it doesn't treat gout.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1918.

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63. A client who was diagnosed with type 1 diabetes14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?

Explanation

RATIONALE: This client's abnormally high blood glucose level indicates hyperglycemia, which typically causespolyuria,polyphagia, andpolydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated withhypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1382.

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64. A physician orders acarbose (Precose), an alpha-glucosidase inhibitor, for a client with type 2 diabetes. Which statement by the client indicates a need for additional teaching?

Explanation

RATIONALE: The client indicates a need for additional teaching if he states that he'll eat sugar if he has hypoglycemia. Acarbose delays glucose absorption. So when treating hypoglycemia, the client should take an oral form of dextrose rather than a product containing table sugar. The alpha-glucosidase inhibitors work by delaying the carbohydrate digestion and glucose absorption, not by stimulating the pancreas to release more insulin. It's safe for the client to be on a regimen that includes insulin and an alpha-glucosidase inhibitor. The client should take the drug at the start of a meal, not 30 minutes to 1 hour before.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 67.

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65. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome?

Explanation

RATIONALE: Regardless of the client's medical history, rapid fluid resuscitationis critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly ordered fluids include dextran (in cases ofhypovolemicshock),isotonicnormal saline solution and, when the client is stabilized,hypotonichalf-normal saline solution.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1416.

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66. A client is diagnosed with diabetes mellitus. The physician orders 15 units of U-100 regular insulin and 35 units of U-100 isophane insulinsuspension(NPH) to be taken before breakfast. The nurse checks the medication order, assembles equipment, washes her hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?

Explanation

RATIONALE: To avoid creating a vacuum, the nurse must inject exactly the same amount of air into a multidose vial to replace the amount of medication to be withdrawn. She should follow these steps: (1) Inject air into the vial from which the second insulin dose will be withdrawn (isophane insulin). (2) Inject air into the vial from which insulin will be withdrawn first (regular insulin). (3) With the needle inserted into the regular insulin vial, withdraw the correct amount. (4) With 15 units of regular insulin in the syringe, carefully withdraw 35 units of NPH, for a total of 50 units in the syringe. Options 2 and 4 are incorrect because regular insulin must be withdrawn first. Option 3 is incorrect because the nurse must not insert air into a multiple-dose vial with a syringe containing medication.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 828.

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67. A client with diabetes mellitusdevelops sinusitis andotitis mediaaccompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?

Explanation

RATIONALE: Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased byhypothyroidism, decreased food intake, exercise, and some medications.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1414.

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68. A nurse hears a staff member giving incorrect information to the family of a client newly diagnosed with diabetes mellituswho is being discharged to home. The nurse wants to make sure the family has the proper information before the client is discharged. What should she do?

Explanation

RATIONALE: The nurse should use this situation as a learning opportunity for her colleague by asking her to step outside of the room to discuss the situation. Telling the nurse that she's providing incorrect information is too blunt and corrective. Going into the room to correct the teaching would undermine the nurse doing the teaching.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 522.

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69. A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome(HHNS). Which other laboratory finding should the nurse anticipate?

Explanation

RATIONALE: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis.Metabolic acidosis, not serum alkalosis, may occur in HHNS.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1416.

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70. Nursing care for a client in addisonian crisisshould include which intervention?

Explanation

RATIONALE: The client in addisonian crisis has a reduced ability to cope with stress as a result of an inability to produce corticosteroids. A private room is easy to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1478.

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71. A nurse is teaching a client with diabetes mellitusabout self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:

Explanation

RATIONALE: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1387.

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72. A nurse has just been trained in how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor?

Explanation

RATIONALE: To obtain accurate readings, the nurse should calibrate the machine whenever a new battery is installed. To adhere to standard precautionsand prevent contact with blood, the nurse's hands should remain gloved throughout blood glucose testing. The nurse should drop the blood — not smear it — onto the reagent pad because smearing can cause an inaccurate reading. To help ensure accurate results, the nurse shouldn't start the timer before the blood sample is collected.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1467.

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73. A client with hyperthyroidismis about to receive radioactive iodine as an outpatient. What safety measures should the nurse teach the client to protect his family while he undergoes treatment?

Explanation

RATIONALE: The nurse should teach this client about safety precautions, such as using disposable eating utensils and avoiding kissing, sexual intercourse, and holding babies. These measures help limit exposing others to the radioactive iodine. Good hand washing is always necessary to prevent the spread of infection; however, it provides no protection against radioactive iodine therapy. Isolation isn't necessary, but radiation precautions are.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1460.

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74. A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?

Explanation

RATIONALE: Telling the parents that the number of blood draws will decrease as their child's glucose levels stabilize engages them in the learning process and gives them hope that the present discomfort will end as the child's condition improves. Telling the parents that their child won't remember the experience disregards their concerns and anxiety. The nurse shouldn't offer to ask the physician if he can reduce the number of blood draws; the physician needs the laboratory results to monitor the child's condition properly. Although telling the parents that the laboratory technicians are gentle and use tiny needles may be reassuring, it isn't the most appropriate response.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1390.

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75. A nurse administered neutral protamine Hagedorn (NPH) insulin to a client with diabetes mellitusat 7 a.m. At what time should the nurse expect the client to be most at risk forhypoglycemia?

Explanation

RATIONALE: NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 to 7 p.m.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 631.

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76. A client with pancreatitisis admitted to the medical intensive care unit. Which nursing intervention is most appropriate?

Explanation

RATIONALE: Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve the antecubital site for a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1362.

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77. A client with type 1 diabetesis admitted to an acute care facility withdiabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first?

Explanation

RATIONALE: The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1414.

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78. A client with long-standing type 1 diabetesis admitted to the hospital with unstableangina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

Explanation

RATIONALE: The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustmentandDefensive coping.Because the nurse, not the client, questioned the client's health practices related to diabetes management, the nursing diagnosis ofHealth-seeking behaviorsisn't warranted.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1390.

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79. A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching?

Explanation

RATIONALE: The client requires additional teaching if he states that he will increase his calcium intake. Hyperparathyroidism causes extreme increases in serum calcium levels. The client should increase his fluid intake, but he should limit his calcium and vitamin D intake. The client should continue to take pain mediations as scheduled and have regular follow-up visits with his physician. Tingling around the lips is a sign of hypercalcemia and should be reported to the physician immediately.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1472.

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80. A client newly diagnosed with diabetes mellitusasks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?

Explanation

RATIONALE: The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1391.

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81. When caring for a client with a history of hypoglycemia, the nurse should avoid administering a drug that may potentiate hypoglycemia. Which drug fits this description?

Explanation

RATIONALE: Sulfisoxazole and other sulfonamides are chemically related to oral antidiabetic agents and may precipitate hypoglycemia. Mexiletine, an antiarrhythmic, is used to treat refractory ventricular arrhythmias; it doesn't cause hypoglycemia. Prednisone, a corticosteroid, is associated with hyperglycemia. Lithium may cause transient hyperglycemia, not hypoglycemia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1089.

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82. A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:

Explanation

RATIONALE: Attending to the mother's needs is a critical part of caring for a sick child. In this case however, administering insulin in a prompt manner supersedes the mother's needs. By informing the mother that she's going to administer the insulin and will then make time to talk with her, the nurse recognizes the mother's needs as legitimate. She provides a reasonable response while attending to the priority of administering insulin as soon as possible. Telling the mother that she can't talk with her or telling her to wait for the physician could increase the mother's fear and anxiety. The nurse shouldn't tell the mother that everything will be fine; the nurse doesn't know that everything will be fine.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1402.

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83. During a follow-up visit to the physician, a client with hyperparathyroidismasks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:

Explanation

RATIONALE: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1443.

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84. A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:

Explanation

RATIONALE: Hypoparathyroidism may slow bone resorption, reduce the serum calcium level, and cause profound neuromuscular irritability(as evidenced bytetany). Hypoparathyroidism doesn't alter blood pressure or affect the thirst mechanism, which usually is triggered by fluid volume deficit.Gastritisdoesn't cause or result from hypoparathyroidism.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1472.

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85. A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?

Explanation

RATIONALE: Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1480.

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86. Which statement best indicates that a client understands how to administer his own insulin injections?

Explanation

RATIONALE: The fact that the client has written down each step of insulin administration provides the best assurance that he'll follow through with all the proper steps. Awareness of air bubbles and hand washing indicate that the client understands certain aspects of giving an injection, but doesn't confirm he understands all of the steps. Saying that he can ask a friend or neighbor for help indicates a need for further instruction.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1404.

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87. A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytomawill be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client?

Explanation

Pheochromocytoma is a tumor of the adrenal gland that can cause excess release of catecholamines such as adrenaline and noradrenaline. Dopamine is often used in the treatment of pheochromocytoma to help stabilize blood pressure and manage symptoms associated with catecholamine excess.

Submit
88. On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first?

Explanation

RATIONALE: The nurse should assess the client with chest pressure first because he might be experiencing a myocardial infarction. The blood glucose levels in 20-year-old client and 80-year-old client are abnormal, but not life threatening; therefore, these clients don't require immediate attention. After assessing the client with chest pressure, the nurse should assess the client experiencing nausea and vomiting.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE:Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care,6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 291.

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89. When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of:

Explanation

RATIONALE: The nurse should encourage fluid intake to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1471.

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90. A client with type 1 diabetesis scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

Explanation

RATIONALE: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 units of NPH and 9 units of regular insulin. The other choices are incorrect dosages for the ordered insulin.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1392.

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91. A client is scheduled for a transsphenoidal hypophysectomyto remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by:

Explanation

RATIONALE: The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity testing isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of potential complications such asinfection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2302.

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92. A nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by what he's facing and not sure he can handle giving himself insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because she needs the space for clients being admitted. How should the nurse handle the situation?

Explanation

RATIONALE: The nurse's primary concern should be the safety of the client after discharge. She should provide succinct information to the physician concerning the client's needs, express her concern about ensuring the client's safety, and ask the physician to delay the client's discharge. The nurse shouldn't suggest that the client rely on a friend or family member because she doesn't know if a friend or family member will be available to help. Refusing to rush and telling the charge nurse she isn't sure the client will be safe demonstrate appropriate intentions, but these actions don't alleviate the pressure to discharge the client. Asking a physician to refer the client to a diabetic nurse-educator addresses the client's needs, but isn't the best response because there's no guarantee a diabetic nurse-educator will be available on such short notice.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1410.

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93. Every morning, a client with type 1 diabetesreceives 15 units of Humulin 70/30. What does this type of insulin contain?

Explanation

RATIONALE: Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1392.

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94. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?

Explanation

RATIONALE: A serum glucose level of 618 mg/dl indicates hyperglycemia, which causespolyuriaand fluid volume deficit, makingDeficient fluid volume related to osmotic diuresisthe highest priority. In this client,tachycardiais more likely to result from fluid volume deficit than from decreasedcardiac outputbecause his blood pressure is normal. Although the client's serum glucose is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis ofImbalanced nutrition: Less than body requirementsisn't appropriate. A temperature of 100.6° F isn't life-threatening, eliminating Ineffective thermoregulation as the top priority.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1417.

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95. A physician orders laboratory tests to confirm hyperthyroidismin a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

Explanation

RATIONALE: In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3and T4, as detected by radioimmunoassay, signalhypothyroidism. A below-normal T4level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1460.

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96. A nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be:

Explanation

RATIONALE: The nurse should use routine care responsibilities as teaching opportunities with the intention of preparing the client to understand and eventually manage his disease. Monitoring blood glucose, checking for the presence of ketones, and administering insulin are important when caring for a client with diabetes, but they aren't the priority of care.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et. al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1402.

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97. A client with type 1 diabeteshas been on a regimen of multiple daily injection therapy. He's being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse should tell him that the regimen includes the use of:

Explanation

RATIONALE: A continuous subcutaneous insulin regimen uses a basal rate and boluses of short-acting insulin. Multiple daily injection therapy uses a combination of short-acting and intermediate- or long-acting insulins.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1397.

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98. A client with type 1 diabetesmust undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery?

Explanation

RATIONALE: If the nurse administers the client's normal daily dose of insulin while he's on nothing-by-mouth status before surgery, he'll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren't effective for type 1 diabetes. I.V. insulin infusions aren't necessary to manage blood glucose levels in clients undergoing routine surgery.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1414.

Submit
99. Which condition may contribute to hyperparathyroidism?

Explanation

RATIONALE: Because failing kidneys can't convert vitamin D, the serum calcium level declines. Parathyroid hormone release increases, causing hyperparathyroidism. Thyroidectomy may lead to hypoparathyroidismif the parathyroid is also removed during surgery. Serum calcium level may rise as a result of hyperparathyroidism, so it isn't a contributing factor. Steroid use causes calcium to leave bone, suppressing parathyroid hormone.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1471.

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100. Which laboratory test results should a nurse expect to find in a client diagnosed with Hashimoto's thyroiditis?

Explanation

RATIONALE: Normal thyroid function tests are as follows: T4, 5 to 12 μg/dl; T3, 65 to 195 ng/dl; TSH 0.3 to 5.4 μIU/ml. With Hashimoto's thyroiditis, T4 and T3 levels are typically subnormal and TSH is elevated. With primary hyperthyroidism, T4 and T3 levels are elevated and TSH is subnormal. Withhypothyroidism, T4 is subnormal and T3 and TSH levels are elevated.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1452.

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101. A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?

Explanation

RATIONALE: In diabetes insipidus, excessive polyuriacauses dilute urine, resulting in a below-normal urineosmolalitylevel. At the same time, polyuria depletes the body of water, causingdehydrationthat leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing,11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1447.

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102. Diet and exercise have failed to control a client's blood glucose level. The physician orders glipizide (Glucotrol). After oral administration, the onset of action is:

Explanation

RATIONALE: Glipizide begins to act in 1 to 1½ hours.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 573.

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