Nur 504 / Nur504 Exam 3.

A nurse is caring for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. What actions does the nurse take? (Select all that apply.) a. Administer levothyroxine. b. Administer propranolol. c. Monitor the apical pulse. d. Assess for Trousseau sign. e. Initiate telemetry monitoring. ANS: C, E The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseau sign is a test for hypocalcemia. A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's health teaching? (Select all that apply.) a. Increased carbohydrates b. Decreased fats c. Increased calorie intake d. Supplemental vitamins e. Increased proteins ANS: A, C, E The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. There is no need to decrease fat intake or take supplemental vitamins. The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis. A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, PO2 88 mm Hg ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? a. Administration of oxygen via facemask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The patient who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the patient glucose would be contraindicated. The patient does not require seizure precautions. A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? a. Serum chloride level of 98 mEq/L (98 mmol/L) b. Serum calcium level of 8.8 mg/dL (2.2 mmol/L) c. Serum sodium level of 132 mEq (132 mmol/L) d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L) ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration. The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? a. Diabetic ketoacidosis (DKA) b. Severe hypoglycemia c. chronic kidney disease (CKD) d. Hyperglycemic-hyperosmolar state (HHS) ANS: D The client most likely has diabetes mellitus type 2 and has a high blood glucose causing increased blood osmolarity and dehydration, as evidenced by an insufficient urinary output and increased BUN. Older adults are at the greatest risk for dehydration due to age-related physiologic changes. The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? a. Assess the client's blood glucose level. b. Monitor the client's urinary output every hour. c. Establish intravenous access to provide fluids. d. Give regular insulin per agency policy. ANS: C The first priority in caring for a client with HHS is to increase blood volume to prevent shock or severe hypotension from dehydration. The nurse would monitor vital signs, urinary output, and blood glucose to determine if interventions were effective. Regular insulin is also indicated but not as the first priority action. A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually, patients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur. The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.) a. Warm, dry skin b. Nervousness c. Rapid deep respirations d. Dehydration e. Ketoacidosis f. Blurred vision ANS: B, F The client who has hypoglycemia is often anxious, nervous, and possibly confused. Due to lack of glucose, vision may be blurred or the client may report diplopia (double vision). Clients who have hyperglycemia from diabetes mellitus type 1 have warm skin, Kussmaul respirations that are rapid and deep, dehydration due to elevated blood glucose, and ketoacidosis.