TEST BANK FOR ADULT
HEALTH NURSING EXAM
QUESTIONS WITH RATIONALES
Amnursemismmonitoringmamclientmwhomismtakingmspironolactonemformthemtreatmentmofmhypertension.m
Whichmfindingsmdenotemadversemeffectsmofmthemmedication?mSelectmallmthatmapply.m-
mCORRECTmANSWERm-TallmTmwaves
ProlongedmPRmintervalmHy
peractivembowelmsounds
Rationale:mSpironolactonemismampotassium-sparingmdiuretic.mPotassium-
sparingmdiureticsmcanmcausemhyperkalemia.mCardiovascularmmanifestationsmofmhyperkalemiaminclude
mtallmTmwaves,mwidenedmQRSmcomplexes,mprolongedmPRmintervals,mandmflatmPmwaves.mOthermcardiova
scularmmanifestationsmincludemanmirregularmheartmrate,mdecreasedmbloodmpressure,mandmectopicmhear
tbeats.mMusclemtwitchesmoccurminmhyperkalemia.mHyperactivembowelmsoundsmandmdiarrheamalsomocc
urminmhyperkalemia.mConstipation,mhyporeflexia,mandmshallowmrespirationsmaremsignsmofmhypokalemi
a.
Amnursemismprovidingmdietaryminstructionsmtomamclientmwithmchronicmobstructivempulmonarymdiseasem(C
OPD)mwhomismexperiencingmamlossmofmappetitemandmcomplainsmofmfeelingm"toomfullmtomeat."mWhatmdoes
mthemnursemencouragemthemclientmtomdo?mSelectmallmthatmapply.m-mCORRECTmANSWERm-
Avoidmdrinkingmfluidsmbeforemandmduringmmeals
Selectmfoodsmthatmaremeasymtomchewmandmaremnotmgasmforming
Rationale:mCOPDmismamprogressivemandmirreversiblemconditionmcharacterizedmbymdiminishedminspiratorym
andmexpiratorymcapacitymofmthemlungs.mInstructmthemclientmwhomcomplainsmofmfeelingmtoomfullmtomeat,mto
mavoidmdrinkingmfluidsmbeforemandmduringmthemmeal.mDrymfoodsmsuchmasmcrackersmstimulatemcoughing;mf
oodsmsuchmasmmilkmandmchocolatemmaymincreasemthemthicknessmofmsalivamandmsecretions.mCheesemismcons
tipatingmandmshouldmalsombemavoidedmbymthemclient.mThemnursemshouldmalsomteachmthemclientmaboutmfoo
dsmthatmaremeasymtomchewmandmdomnotmencouragemthemformationmofmgas;mformthismreason,mbroccoli,mwhic
hmismamgas-formingmfood,mshouldmbemavoided.
,Amtuberculinmskinmtestm(TST)mismadministeredmtomamclientmwithmamdiagnosismofmHIVminfection.mForty-
eightmhoursmaftermadministration,mthemnursemchecksmthemtestmsitem(seemimage).m-mCORRECTmANSWERm-
Positive
Rationale:mThemtuberculin,mormTST,mtestmismamreliablemdeterminantmofmtuberculosism(TB)minfection.mAmrea
ctionmmeasuringm5mmmmormmoreminmdiametermismconsideredmpositiveminmamclientmwithmHIVminfection.mAmr
eactionmmeasuringm10mmmmormmoreminmdiametermismconsideredmpositiveminmamnon-
immunosuppressedmclient.mInmthisminstance,mthemareamofmindurationmmeasuresm9mmm,mindicatingmamposi
tivemreaction.mAmpositivemreactionmdoesmnotmmeanmthatmactivemdiseasemismpresent,mbutmitmdoesmindicatem
exposuremtomTBmormthempresencemofminactivem(dormant)mdisease.
Amnursemisminterpretingmamcentralmvenousmpressurem(CVP)mreadingmfrommamclientminmwhommrightmventr
icularmfailuremhasmbeenmdiagnosed.mFrommthismdiagnosis,mthemnursemwouldmexpectmthatmthemmostmlikel
ymresultmismampressuremofm-mCORRECTmANSWERm-14mcmmH2O
Rationale:mCVPmmeasurementsmaremusedmtommonitormbloodmvolumemandmthemadequacymofmvenousmretur
nmtomthemheart.mThemCVPmmeasuresmpressuresmfrommthemrightmatriummormcentralmveins.mThemnormalmCVP
mism7mtom12mcmmH2O.mAnmincreasedmCVPmreadingmmaymindicatemrightmventricularmfailure.mAmlowmCVPmrea
dingmmaymindicatemhypovolemia.mAmreadingmofm4mcmmH2Omismlow.mReadingsmofm8mandm11mcmmH2Omaremn
ormal.mAmreadingmofm14mcmmH2Omismincreased.
Amnursemismcaringmformamclientmwhomhasmjustmundergonemthyroidectomy.mWhichmtechniquemismthembestmw
aymformthemnursemtomassessmthemsurgicalmsitemformbleeding?m-mCORRECTmANSWERm-
Checkingmformmoisturemonmthembackmofmthemdressingmovermthemclient'smneckmandmshoulders
Rationale:mThyroidmsurgerymmaymbemcomplicatedmbymhemorrhage,mrespiratorymdistress,mparathyroidmgl
andminjurym(resultingminmhypocalcemiamandmtetany),mdamagemtomthemlaryngealmnerves,mandmthyroidmsto
rm.
Hemorrhagemismmostmlikelymduringmthem24mhoursmaftermsurgery.mIfmthemclientmismbleedingmaftermsurgery,m
gravitymwillmcausemthembloodmtomseepmdownmthemsidesmofmthemdressingmandmdrainmontomthemunderlyingmb
edmlinensmevenmasmthemtopmofmthemdressingmremainsmcleanmandmdry.mAskingmthemclientmwhethermthemdres
singmfeelsmwetmandmreplacingmthemdrymsterilemdressingmeverym2mhoursmaremnotmthembestmactions.mReplacin
gmthemdressingmfrequentlymwhenmitmismnotmwarrantedmcouldmalsomincreasemthemriskmofminfection.
Amclientmwhomsustainedmammajormburnminjurymismbeginningmtomtakemanmoralmdietmagain.mWhichmbetween
-
mealmmenumselectionsmmeetmthemclient'smneedsmformwoundmhealingmandmtissuemrepair?mSelectmallmthatm
apply.m-mCORRECTmANSWERm-Whole-milkmshakemandmgranola
Bakedmpotatomtoppedmwithmchees
emCheesemandmwhole-
wheatmcrackers
,Rationale:mTomfacilitatemhealingmandmmeetmcontinuedmhighmmetabolicmneeds,mthemclientmwithmammajor
mburnmshouldmeatmamdietmhighminmcalories,mprotein,mandmcarbohydrates.mThismtypemofmdietmalsomkeepsmt
hemclientminmpositivemnitrogenmbalance.mFoodsmsuchmasmmilkshakes,mgranola,mcheese,mandmwhole-
wheatmproductsmaremacceptablemchoices.mThoughmfreshmfruitsmandmvegetablesmandmskimmmilkmaremhig
hminmnutrients,mhigher-
mcaloriemfoods,mincludingmversionsmofmdairymproductsmpreparedmwithmwholemmilk,marempreferableminmth
ismsituation.
Amclientmismfoundmtomhavemhypoparathyroidism.mWhichmnutritionalmsupplementmdoesmthemnurse,mteac
hingmthemclientmaboutmmeasuresmtommanagemthemdisorder,mtellmthemclientmtomtakemonmamdailymbasis?m-
mCORRECTmANSWERm-CalciummcarbonatemwithmvitaminmD
Rationale:mHypoparathyroidismmismanmendocrinemdisorderminmwhichmparathyroidmfunctionmismdecreased.
mThemclientmwithmhypoparathyroidismmismlikelymtomhavemlowmcalciummandmhighmphosphatemlevelsmandmsh
ouldmconsumemamdietmhighminmcalciummbutmlowminmphosphorus.mAdditionally,mthemgenerallymusedmtreatm
entmismcalciummsupplementationm(eithermasmcalciummcarbonatemormcalciummcitrate)mcoupledmwithmvitami
nmDmsupplementation.mVitaminmCmsupplementationmismnotmamtreatmentmmeasuremformthismdisorder.mBet
a-
mcarotenemismincorrect,mbecausemamclientmwithmhypoparathyroidismmtypicallymhasmanmincreasedmphospho
rusmlevel
Amnursemparticipatingminmamfreemhealthmscreeningmatmthemlocalmmallmobtainsmamrandommbloodmglucosemle
velmofm190mmg/dLm(10.6mmmol/L)mandmamtotalmcholesterolmlevelmofm210mmg/dLm(5.4mmmol/L)minmanmothe
rwisemhealthymclient.mWhatmshouldmthemnursemtellmthemclientmtomdomnext?m-mCORRECTmANSWERm-
Callmhismhealthmcaremprovidermtomhavemthesemvaluesmrecheckedmasmsoonmasmpossible
Rationale:mAdultmdiabetesmmellitusmmaymbemdiagnosedmonmthembasismofmsymptomsm(e.g.,mpolydipsia,mpol
yuria,mpolyphagia)mormlaboratorymvalues.mAnmabnormalmglucosemtolerancemtest,mamrandommplasmamgluco
semlevelmgreatermthanm200mmg/dLm(11.1mmmol/L),mandmamfastingmplasmamglucosemlevelmgreatermthanm140
mmg/dLm(7.8mmmol/L)monmtwomseparatemoccasionsmaremallmdiagnosticmofmdiabetesmmellitus.mThemtotalmcho
lesterolmshouldmbemlessmthanm200mmg/dLm(5.2mmmol/L).mConfirmationmofmthismclient'smresultsmismneededm
tomensuremappropriatemdiagnosismandmtherapy.
Levothyroxinemsodiummismprescribedmformamclientmwithmhypothyroidism,mandmthemnursemprovidesminform
ationmtomthemclientmaboutmthemmedication.mWhichmoccurrencesmdoesmthemnursemtellmthemclientmtomreportm
tomthemhealthmcaremprovider?mSelectmallmthatmapply.m-mCORRECTmANSWERm-Chestmpain
PalpitationsmRa
pidmheartmrate
, Rationale:mThemclientmtakingmlevothyroxinemsodiummmaymhavemmanifestationsmofmhypothyroidismmifmthe
mdosagemisminadequatemormmaymexperiencemmanifestationsmofmhyperthyroidismmifmthemdosagemismtoomhig
h.mThyroidmpreparationsmincreasemmetabolicmrate,moxygenmdemands,mandmdemandsmonmthemheart,mwhic
hmmaymresultminmanginamandmcardiacmdysrhythmias.mThemclientmshouldmbeminstructedmtomreportmchestmpa
in,mpalpitations,mormamrapidmheartmratemimmediately.mLethargy,mconstipation,mandmweightmgainmaremsymp
tomsmofmhypothyroidism,mwhichmshouldmimprovemwithmmedicationmtherapym(e.g.,mlevothyroxinemsodium)
.
Amnursemismdevelopingmamplanmofmcaremformanmoldermclientmwithmdiabeticmneuropathymofmthemlowermextre
mitiesmresultingmfrommtypem2mdiabetesmmellitus.mWhichmproblemmdoesmthemnursemrecognizemasmthemhigh
estmprioritymformthismclient?m-mCORRECTmANSWERm-Increasedmriskmforminjury
Rationale:mThemclientmwithmdiabeticmneuropathymofmthemlowermextremitiesmhasmamdiminishedmsensationmi
nmthemlegsmandmfeet.mThismclientmismatmriskmformtissueminjurymandmformfallsmasmamresultmofmthismnervousmsyst
emmimpairment.mThereforemthemhighestmprioritymnursingmproblemmismincreasedmriskmforminjury.mIncreased
mriskmofmdepressionmandmchangeminmbodymimagemaremmorempsychosocialminmnaturemand,masmsuch,maremsec
ondarymneeds.mAmlowermlevelmofmphysicalmactivitymmaymbemamproblemmbutmismnotmthempriority.
ThemnursemismteachingmamclientmwithmnewlymdiagnosedmdiabetesmmellitusmwhomhasmbeenmprescribedmNP
Hminsulinmhowmtomrecognizemthemsignsmofmhypoglycemia.mThemclientmstatesmthatmhemmustmlookmformcert
ainmsignsmandmsymptomsminmthemlatemafternoon,mindicatingmtomthemnursemthatmhemhasmunderstoodmthemi
nstructions.
Whatmaremthesemsignsmandmsymptoms?mSelectmallmthatmapply.m-mCORRECTmANSWERm-
ShakinessmBlurredmvision
Feelingsmofmhunger
Rationale:mThemclientmtakingmNPHminsulinmexperiencesmpeakmmedicationmeffectsm6mtom12mhoursmaftermad
ministration.mWhenmthemmedication'smactionmpeaks,mthemclientmismatmriskmofmhypoglycemiamifmfoodmintak
emisminsufficient.mThemnursemteachesmthemclientmtombemalertmformsignsmandmsymptomsmofmhypoglycemia,mi
ncludingmanxiety,mconfusion,mdifficultymconcentrating,mblurredmvision,mcoldmsweats,mheadache,mincreased
mpulse,mshakiness,mandmhunger.mThemothermoptionsmaremsignsmandmsymptomsmofmhyperglycemia
Glargineminsulinmismprescribedmformamclientmwithmtypem1mdiabetesmmellitus.mWhatmdoesmthemnursemtellmth
emclientmaboutmthismtypemofminsulin?mSelectmallmthatmapplym-mCORRECTmANSWERm-
Itmdoesmnotmhavemampeakmeffect.
Itmismusuallymgivenmoncemdaily,matmbedtim
e.mItmusuallymhasmam24-
hourmdurationmofmaction
HEALTH NURSING EXAM
QUESTIONS WITH RATIONALES
Amnursemismmonitoringmamclientmwhomismtakingmspironolactonemformthemtreatmentmofmhypertension.m
Whichmfindingsmdenotemadversemeffectsmofmthemmedication?mSelectmallmthatmapply.m-
mCORRECTmANSWERm-TallmTmwaves
ProlongedmPRmintervalmHy
peractivembowelmsounds
Rationale:mSpironolactonemismampotassium-sparingmdiuretic.mPotassium-
sparingmdiureticsmcanmcausemhyperkalemia.mCardiovascularmmanifestationsmofmhyperkalemiaminclude
mtallmTmwaves,mwidenedmQRSmcomplexes,mprolongedmPRmintervals,mandmflatmPmwaves.mOthermcardiova
scularmmanifestationsmincludemanmirregularmheartmrate,mdecreasedmbloodmpressure,mandmectopicmhear
tbeats.mMusclemtwitchesmoccurminmhyperkalemia.mHyperactivembowelmsoundsmandmdiarrheamalsomocc
urminmhyperkalemia.mConstipation,mhyporeflexia,mandmshallowmrespirationsmaremsignsmofmhypokalemi
a.
Amnursemismprovidingmdietaryminstructionsmtomamclientmwithmchronicmobstructivempulmonarymdiseasem(C
OPD)mwhomismexperiencingmamlossmofmappetitemandmcomplainsmofmfeelingm"toomfullmtomeat."mWhatmdoes
mthemnursemencouragemthemclientmtomdo?mSelectmallmthatmapply.m-mCORRECTmANSWERm-
Avoidmdrinkingmfluidsmbeforemandmduringmmeals
Selectmfoodsmthatmaremeasymtomchewmandmaremnotmgasmforming
Rationale:mCOPDmismamprogressivemandmirreversiblemconditionmcharacterizedmbymdiminishedminspiratorym
andmexpiratorymcapacitymofmthemlungs.mInstructmthemclientmwhomcomplainsmofmfeelingmtoomfullmtomeat,mto
mavoidmdrinkingmfluidsmbeforemandmduringmthemmeal.mDrymfoodsmsuchmasmcrackersmstimulatemcoughing;mf
oodsmsuchmasmmilkmandmchocolatemmaymincreasemthemthicknessmofmsalivamandmsecretions.mCheesemismcons
tipatingmandmshouldmalsombemavoidedmbymthemclient.mThemnursemshouldmalsomteachmthemclientmaboutmfoo
dsmthatmaremeasymtomchewmandmdomnotmencouragemthemformationmofmgas;mformthismreason,mbroccoli,mwhic
hmismamgas-formingmfood,mshouldmbemavoided.
,Amtuberculinmskinmtestm(TST)mismadministeredmtomamclientmwithmamdiagnosismofmHIVminfection.mForty-
eightmhoursmaftermadministration,mthemnursemchecksmthemtestmsitem(seemimage).m-mCORRECTmANSWERm-
Positive
Rationale:mThemtuberculin,mormTST,mtestmismamreliablemdeterminantmofmtuberculosism(TB)minfection.mAmrea
ctionmmeasuringm5mmmmormmoreminmdiametermismconsideredmpositiveminmamclientmwithmHIVminfection.mAmr
eactionmmeasuringm10mmmmormmoreminmdiametermismconsideredmpositiveminmamnon-
immunosuppressedmclient.mInmthisminstance,mthemareamofmindurationmmeasuresm9mmm,mindicatingmamposi
tivemreaction.mAmpositivemreactionmdoesmnotmmeanmthatmactivemdiseasemismpresent,mbutmitmdoesmindicatem
exposuremtomTBmormthempresencemofminactivem(dormant)mdisease.
Amnursemisminterpretingmamcentralmvenousmpressurem(CVP)mreadingmfrommamclientminmwhommrightmventr
icularmfailuremhasmbeenmdiagnosed.mFrommthismdiagnosis,mthemnursemwouldmexpectmthatmthemmostmlikel
ymresultmismampressuremofm-mCORRECTmANSWERm-14mcmmH2O
Rationale:mCVPmmeasurementsmaremusedmtommonitormbloodmvolumemandmthemadequacymofmvenousmretur
nmtomthemheart.mThemCVPmmeasuresmpressuresmfrommthemrightmatriummormcentralmveins.mThemnormalmCVP
mism7mtom12mcmmH2O.mAnmincreasedmCVPmreadingmmaymindicatemrightmventricularmfailure.mAmlowmCVPmrea
dingmmaymindicatemhypovolemia.mAmreadingmofm4mcmmH2Omismlow.mReadingsmofm8mandm11mcmmH2Omaremn
ormal.mAmreadingmofm14mcmmH2Omismincreased.
Amnursemismcaringmformamclientmwhomhasmjustmundergonemthyroidectomy.mWhichmtechniquemismthembestmw
aymformthemnursemtomassessmthemsurgicalmsitemformbleeding?m-mCORRECTmANSWERm-
Checkingmformmoisturemonmthembackmofmthemdressingmovermthemclient'smneckmandmshoulders
Rationale:mThyroidmsurgerymmaymbemcomplicatedmbymhemorrhage,mrespiratorymdistress,mparathyroidmgl
andminjurym(resultingminmhypocalcemiamandmtetany),mdamagemtomthemlaryngealmnerves,mandmthyroidmsto
rm.
Hemorrhagemismmostmlikelymduringmthem24mhoursmaftermsurgery.mIfmthemclientmismbleedingmaftermsurgery,m
gravitymwillmcausemthembloodmtomseepmdownmthemsidesmofmthemdressingmandmdrainmontomthemunderlyingmb
edmlinensmevenmasmthemtopmofmthemdressingmremainsmcleanmandmdry.mAskingmthemclientmwhethermthemdres
singmfeelsmwetmandmreplacingmthemdrymsterilemdressingmeverym2mhoursmaremnotmthembestmactions.mReplacin
gmthemdressingmfrequentlymwhenmitmismnotmwarrantedmcouldmalsomincreasemthemriskmofminfection.
Amclientmwhomsustainedmammajormburnminjurymismbeginningmtomtakemanmoralmdietmagain.mWhichmbetween
-
mealmmenumselectionsmmeetmthemclient'smneedsmformwoundmhealingmandmtissuemrepair?mSelectmallmthatm
apply.m-mCORRECTmANSWERm-Whole-milkmshakemandmgranola
Bakedmpotatomtoppedmwithmchees
emCheesemandmwhole-
wheatmcrackers
,Rationale:mTomfacilitatemhealingmandmmeetmcontinuedmhighmmetabolicmneeds,mthemclientmwithmammajor
mburnmshouldmeatmamdietmhighminmcalories,mprotein,mandmcarbohydrates.mThismtypemofmdietmalsomkeepsmt
hemclientminmpositivemnitrogenmbalance.mFoodsmsuchmasmmilkshakes,mgranola,mcheese,mandmwhole-
wheatmproductsmaremacceptablemchoices.mThoughmfreshmfruitsmandmvegetablesmandmskimmmilkmaremhig
hminmnutrients,mhigher-
mcaloriemfoods,mincludingmversionsmofmdairymproductsmpreparedmwithmwholemmilk,marempreferableminmth
ismsituation.
Amclientmismfoundmtomhavemhypoparathyroidism.mWhichmnutritionalmsupplementmdoesmthemnurse,mteac
hingmthemclientmaboutmmeasuresmtommanagemthemdisorder,mtellmthemclientmtomtakemonmamdailymbasis?m-
mCORRECTmANSWERm-CalciummcarbonatemwithmvitaminmD
Rationale:mHypoparathyroidismmismanmendocrinemdisorderminmwhichmparathyroidmfunctionmismdecreased.
mThemclientmwithmhypoparathyroidismmismlikelymtomhavemlowmcalciummandmhighmphosphatemlevelsmandmsh
ouldmconsumemamdietmhighminmcalciummbutmlowminmphosphorus.mAdditionally,mthemgenerallymusedmtreatm
entmismcalciummsupplementationm(eithermasmcalciummcarbonatemormcalciummcitrate)mcoupledmwithmvitami
nmDmsupplementation.mVitaminmCmsupplementationmismnotmamtreatmentmmeasuremformthismdisorder.mBet
a-
mcarotenemismincorrect,mbecausemamclientmwithmhypoparathyroidismmtypicallymhasmanmincreasedmphospho
rusmlevel
Amnursemparticipatingminmamfreemhealthmscreeningmatmthemlocalmmallmobtainsmamrandommbloodmglucosemle
velmofm190mmg/dLm(10.6mmmol/L)mandmamtotalmcholesterolmlevelmofm210mmg/dLm(5.4mmmol/L)minmanmothe
rwisemhealthymclient.mWhatmshouldmthemnursemtellmthemclientmtomdomnext?m-mCORRECTmANSWERm-
Callmhismhealthmcaremprovidermtomhavemthesemvaluesmrecheckedmasmsoonmasmpossible
Rationale:mAdultmdiabetesmmellitusmmaymbemdiagnosedmonmthembasismofmsymptomsm(e.g.,mpolydipsia,mpol
yuria,mpolyphagia)mormlaboratorymvalues.mAnmabnormalmglucosemtolerancemtest,mamrandommplasmamgluco
semlevelmgreatermthanm200mmg/dLm(11.1mmmol/L),mandmamfastingmplasmamglucosemlevelmgreatermthanm140
mmg/dLm(7.8mmmol/L)monmtwomseparatemoccasionsmaremallmdiagnosticmofmdiabetesmmellitus.mThemtotalmcho
lesterolmshouldmbemlessmthanm200mmg/dLm(5.2mmmol/L).mConfirmationmofmthismclient'smresultsmismneededm
tomensuremappropriatemdiagnosismandmtherapy.
Levothyroxinemsodiummismprescribedmformamclientmwithmhypothyroidism,mandmthemnursemprovidesminform
ationmtomthemclientmaboutmthemmedication.mWhichmoccurrencesmdoesmthemnursemtellmthemclientmtomreportm
tomthemhealthmcaremprovider?mSelectmallmthatmapply.m-mCORRECTmANSWERm-Chestmpain
PalpitationsmRa
pidmheartmrate
, Rationale:mThemclientmtakingmlevothyroxinemsodiummmaymhavemmanifestationsmofmhypothyroidismmifmthe
mdosagemisminadequatemormmaymexperiencemmanifestationsmofmhyperthyroidismmifmthemdosagemismtoomhig
h.mThyroidmpreparationsmincreasemmetabolicmrate,moxygenmdemands,mandmdemandsmonmthemheart,mwhic
hmmaymresultminmanginamandmcardiacmdysrhythmias.mThemclientmshouldmbeminstructedmtomreportmchestmpa
in,mpalpitations,mormamrapidmheartmratemimmediately.mLethargy,mconstipation,mandmweightmgainmaremsymp
tomsmofmhypothyroidism,mwhichmshouldmimprovemwithmmedicationmtherapym(e.g.,mlevothyroxinemsodium)
.
Amnursemismdevelopingmamplanmofmcaremformanmoldermclientmwithmdiabeticmneuropathymofmthemlowermextre
mitiesmresultingmfrommtypem2mdiabetesmmellitus.mWhichmproblemmdoesmthemnursemrecognizemasmthemhigh
estmprioritymformthismclient?m-mCORRECTmANSWERm-Increasedmriskmforminjury
Rationale:mThemclientmwithmdiabeticmneuropathymofmthemlowermextremitiesmhasmamdiminishedmsensationmi
nmthemlegsmandmfeet.mThismclientmismatmriskmformtissueminjurymandmformfallsmasmamresultmofmthismnervousmsyst
emmimpairment.mThereforemthemhighestmprioritymnursingmproblemmismincreasedmriskmforminjury.mIncreased
mriskmofmdepressionmandmchangeminmbodymimagemaremmorempsychosocialminmnaturemand,masmsuch,maremsec
ondarymneeds.mAmlowermlevelmofmphysicalmactivitymmaymbemamproblemmbutmismnotmthempriority.
ThemnursemismteachingmamclientmwithmnewlymdiagnosedmdiabetesmmellitusmwhomhasmbeenmprescribedmNP
Hminsulinmhowmtomrecognizemthemsignsmofmhypoglycemia.mThemclientmstatesmthatmhemmustmlookmformcert
ainmsignsmandmsymptomsminmthemlatemafternoon,mindicatingmtomthemnursemthatmhemhasmunderstoodmthemi
nstructions.
Whatmaremthesemsignsmandmsymptoms?mSelectmallmthatmapply.m-mCORRECTmANSWERm-
ShakinessmBlurredmvision
Feelingsmofmhunger
Rationale:mThemclientmtakingmNPHminsulinmexperiencesmpeakmmedicationmeffectsm6mtom12mhoursmaftermad
ministration.mWhenmthemmedication'smactionmpeaks,mthemclientmismatmriskmofmhypoglycemiamifmfoodmintak
emisminsufficient.mThemnursemteachesmthemclientmtombemalertmformsignsmandmsymptomsmofmhypoglycemia,mi
ncludingmanxiety,mconfusion,mdifficultymconcentrating,mblurredmvision,mcoldmsweats,mheadache,mincreased
mpulse,mshakiness,mandmhunger.mThemothermoptionsmaremsignsmandmsymptomsmofmhyperglycemia
Glargineminsulinmismprescribedmformamclientmwithmtypem1mdiabetesmmellitus.mWhatmdoesmthemnursemtellmth
emclientmaboutmthismtypemofminsulin?mSelectmallmthatmapplym-mCORRECTmANSWERm-
Itmdoesmnotmhavemampeakmeffect.
Itmismusuallymgivenmoncemdaily,matmbedtim
e.mItmusuallymhasmam24-
hourmdurationmofmaction
