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Michael is a 24 year old man who presents with a 6 hour history of sudden
onset of inability to raise his eyebrow or smile on the right side. He also
reports decreased lacrimation in the right eye and difficulty closing the
right eyelid. The rest of his health history and physical exam is otherwise
unremarkable. This likely represents paralysis of cranial nerve (CN): III,
VII, IV, VII - ✔✔Answer: d (KNOW HOW TO ASSESS ALL CRANIAL
NERVES)
The nurse is evaluates the client who is being treated for DKA. Which
finding indicates that the client is responding to the treatment plan? Eyes
sunken and skin flushed, Skin moist with rapid elastic recoil, Serum
potassium level is 3.3 mEq/L, ABG results are pH 7.25, Paco2 30, HCO3 17
- ✔✔Answer: b - these are signs that the patient is well hydrated
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,A - incorrect - s/sx of dehydration
C - incorrect - hypokalemia
D - incorrect - you might see these ABG results in the DKA patient when
they first present to the hospital
The nurse is assess the client who has Type II Diabetes. Which findings
indicate to the nurse that the client is experiencing HHNS? Select all that
apply
Serum osmolality 364 mOsm/kg
Blood glucose level 160 mg/dL
Very dry mucous membranes
Blood pressure of 90/42 mm Hg
Urine output 500 mL past 8 hours - ✔✔Answer: a, c & d
Serum osmolality of 364 is elevated. The extremely high blood glucose
levels in HHNS increase serum osmolality.
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, Blood glucose levels for HHNS are usually over 600 mg/dL
Persistent hyperglycemia in HHNS causes osmotic diuresis, a loss of water
and electrolytes and extreme dehydration. Very dry mucous membranes
are a sign of dehydration.
Hypotension from the loss of water and electrolytes in HHNS
Urine output of 500 mL in 8 hours is normal. Clients with HHNS
experience polyuria.
The client develops SIADH secondary to a pituitary tumor. The client's
assessment findings include thirst, weight gain, fatigue, and a serum
sodium of 127 mEq/L. Which intervention, if prescribed should the nurse
implement to treat SIADH?
Elevate the head of the bed 55 degrees
Administer vasopressin IV
Restrict fluids to 800-1000 mL per day
Give 0.3% sodium chloride per IV infusion - ✔✔Answer: c
Incorrect - position client to promote venous return to the heart
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