TEST BANK FOR ADULT
x x x x
HEALTH NURSING EXAM QUESTIONS WITH RATIONALES
x x x x x x
x
A xnurse xis xmonitoring xa xclient xwho xis xtaking xspironolactone xfor xthe xtreatment xof xhypertension.
xWhich xfindings xdenote xadverse xeffects xof xthe xmedication? xSelect xall xthat xapply. x- xCORRECT
xANSWER x-Tall xT xwaves x
Prolonged xPR xinterval x
Hyperactive xbowel xsounds x
Rationale: xSpironolactone xis xa xpotassium-sparing xdiuretic. xPotassium-sparing xdiuretics xcan xcause
xhyperkalemia. xCardiovascular xmanifestations xof xhyperkalemia xinclude xtall xT xwaves, xwidened xQRS
xcomplexes, xprolonged xPR xintervals, xand xflat xP xwaves. xOther xcardiovascular xmanifestations xinclude
xan xirregular xheart xrate, xdecreased xblood xpressure, xand xectopic xheartbeats. xMuscle xtwitches xoccur
xin xhyperkalemia. xHyperactive xbowel xsounds xand xdiarrhea xalso xoccur xin xhyperkalemia. xConstipation,
xhyporeflexia, xand xshallow xrespirations xare xsigns xof xhypokalemia. x
x
A xnurse xis xproviding xdietary xinstructions xto xa xclient xwith xchronic xobstructive xpulmonary xdisease
x(COPD) xwho xis xexperiencing xa xloss xof xappetite xand xcomplains xof xfeeling x"too xfull xto xeat." xWhat
xdoes xthe xnurse xencourage xthe xclient xto xdo? xSelect xall xthat xapply. x- xCORRECT xANSWER x-Avoid
xdrinking xfluids xbefore xand xduring xmeals x
Select xfoods xthat xare xeasy xto xchew xand xare xnot xgas xforming x
Rationale: xCOPD xis xa xprogressive xand xirreversible xcondition xcharacterized xby xdiminished xinspiratory
xand xexpiratory xcapacity xof xthe xlungs. xInstruct xthe xclient xwho xcomplains xof xfeeling xtoo xfull xto xeat,
xto xavoid xdrinking xfluids xbefore xand xduring xthe xmeal. xDry xfoods xsuch xas xcrackers xstimulate
xcoughing; xfoods xsuch xas xmilk xand xchocolate xmay xincrease xthe xthickness xof xsaliva xand xsecretions.
xCheese xis xconstipating xand xshould xalso xbe xavoided xby xthe xclient. xThe xnurse xshould xalso xteach xthe
xclient xabout xfoods xthat xare xeasy xto xchew xand xdo xnot xencourage xthe xformation xof xgas; xfor xthis
xreason, xbroccoli, xwhich xis xa xgas-forming xfood, xshould xbe xavoided. x
x
A xtuberculin xskin xtest x(TST) xis xadministered xto xa xclient xwith xa xdiagnosis xof xHIV xinfection. xForty-eight
xhours xafter xadministration, xthe xnurse xchecks xthe xtest xsite x(see ximage). x- xCORRECT xANSWER x-
Positive x
Rationale: xThe xtuberculin, xor xTST, xtest xis xa xreliable xdeterminant xof xtuberculosis x(TB) xinfection. xA
xreaction xmeasuring x5 xmm xor xmore xin xdiameter xis xconsidered xpositive xin xa xclient xwith xHIV
xinfection. xA xreaction xmeasuring x10 xmm xor xmore xin xdiameter xis xconsidered xpositive xin xa xnon-
immunosuppressed xclient. xIn xthis xinstance, xthe xarea xof xinduration xmeasures x9 xmm, xindicating xa
,positive xreaction. xA xpositive xreaction xdoes xnot xmean xthat xactive xdisease xis xpresent, xbut xit xdoes
x
indicate xexposure xto xTB xor xthe xpresence xof xinactive x(dormant) xdisease. x
x
x
A xnurse xis xinterpreting xa xcentral xvenous xpressure x(CVP) xreading xfrom xa xclient xin xwhom xright
xventricular xfailure xhas xbeen xdiagnosed. xFrom xthis xdiagnosis, xthe xnurse xwould xexpect xthat xthe xmost
xlikely xresult xis xa xpressure xof x- xCORRECT xANSWER x-14 xcm xH2O x
Rationale: xCVP xmeasurements xare xused xto xmonitor xblood xvolume xand xthe xadequacy xof xvenous
xreturn xto xthe xheart. xThe xCVP xmeasures xpressures xfrom xthe xright xatrium xor xcentral xveins. xThe
xnormal xCVP xis x7 xto x12 xcm xH2O. xAn xincreased xCVP xreading xmay xindicate xright xventricular xfailure. xA
xlow xCVP xreading xmay xindicate xhypovolemia. xA xreading xof x4 xcm xH2O xis xlow. xReadings xof x8 xand x11
xcm xH2O xare xnormal. xA xreading xof x14 xcm xH2O xis xincreased. x
x
A xnurse xis xcaring xfor xa xclient xwho xhas xjust xundergone xthyroidectomy. xWhich xtechnique xis xthe xbest
xway xfor xthe xnurse xto xassess xthe xsurgical xsite xfor xbleeding? x- xCORRECT xANSWER x-Checking xfor
xmoisture xon xthe xback xof xthe xdressing xover xthe xclient's xneck xand xshoulders x
Rationale: xThyroid xsurgery xmay xbe xcomplicated xby xhemorrhage, xrespiratory xdistress, xparathyroid
xgland xinjury x(resulting xin xhypocalcemia xand xtetany), xdamage xto xthe xlaryngeal xnerves, xand xthyroid
xstorm. xHemorrhage xis xmost xlikely xduring xthe x24 xhours xafter xsurgery. xIf xthe xclient xis xbleeding xafter
xsurgery, xgravity xwill xcause xthe xblood xto xseep xdown xthe xsides xof xthe xdressing xand xdrain xonto xthe
xunderlying xbed xlinens xeven xas xthe xtop xof xthe xdressing xremains xclean xand xdry. xAsking xthe xclient
xwhether xthe xdressing xfeels xwet xand xreplacing xthe xdry xsterile xdressing xevery x2 xhours xare xnot xthe
xbest xactions. xReplacing xthe xdressing xfrequently xwhen xit xis xnot xwarranted xcould xalso xincrease xthe
xrisk xof xinfection. x
x
A xclient xwho xsustained xa xmajor xburn xinjury xis xbeginning xto xtake xan xoral xdiet xagain. xWhich
xbetween-meal xmenu xselections xmeet xthe xclient's xneeds xfor xwound xhealing xand xtissue xrepair?
xSelect xall xthat xapply. x- xCORRECT xANSWER x-Whole-milk xshake xand xgranola x
x Baked xpotato xtopped xwith xcheese x
x Cheese xand xwhole-wheat xcrackers x
Rationale: xTo xfacilitate xhealing xand xmeet xcontinued xhigh xmetabolic xneeds, xthe xclient xwith xa xmajor
xburn xshould xeat xa xdiet xhigh xin xcalories, xprotein, xand xcarbohydrates. xThis xtype xof xdiet xalso xkeeps
xthe xclient xin xpositive xnitrogen xbalance. xFoods xsuch xas xmilkshakes, xgranola, xcheese, xand xwhole-
wheat xproducts xare xacceptable xchoices. xThough xfresh xfruits xand xvegetables xand xskim xmilk xare xhigh
xin xnutrients, xhighercalorie xfoods, xincluding xversions xof xdairy xproducts xprepared xwith xwhole xmilk,
xare xpreferable xin xthis xsituation. x
x
,A xclient xis xfound xto xhave xhypoparathyroidism. xWhich xnutritional xsupplement xdoes xthe xnurse,
xteaching xthe xclient xabout xmeasures xto xmanage xthe xdisorder, xtell xthe xclient xto xtake xon xa xdaily
xbasis? x- xCORRECT xANSWER x-Calcium xcarbonate xwith xvitamin xD x
Rationale: xHypoparathyroidism xis xan xendocrine xdisorder xin xwhich xparathyroid xfunction xis xdecreased.
xThe xclient xwith xhypoparathyroidism xis xlikely xto xhave xlow xcalcium xand xhigh xphosphate xlevels xand
xshould xconsume xa xdiet xhigh xin xcalcium xbut xlow xin xphosphorus. xAdditionally, xthe xgenerally xused
xtreatment xis xcalcium xsupplementation x(either xas xcalcium xcarbonate xor xcalcium xcitrate) xcoupled xwith
xvitamin xD x
supplementation. xVitamin xC xsupplementation xis xnot xa xtreatment xmeasure xfor xthis xdisorder.
xBetacarotene xis xincorrect, xbecause xa xclient xwith xhypoparathyroidism xtypically xhas xan xincreased
xphosphorus xlevel x
x
A xnurse xparticipating xin xa xfree xhealth xscreening xat xthe xlocal xmall xobtains xa xrandom xblood xglucose
xlevel xof x190 xmg/dL x(10.6 xmmol/L) xand xa xtotal xcholesterol xlevel xof x210 xmg/dL x(5.4 xmmol/L) xin xan
xotherwise xhealthy xclient. xWhat xshould xthe xnurse xtell xthe xclient xto xdo xnext? x- xCORRECT xANSWER x-
Call xhis xhealth xcare xprovider xto xhave xthese xvalues xrechecked xas xsoon xas xpossible x
Rationale: xAdult xdiabetes xmellitus xmay xbe xdiagnosed xon xthe xbasis xof xsymptoms x(e.g., xpolydipsia,
xpolyuria, xpolyphagia) xor xlaboratory xvalues. xAn xabnormal xglucose xtolerance xtest, xa xrandom xplasma
xglucose xlevel xgreater xthan x200 xmg/dL x(11.1 xmmol/L), xand xa xfasting xplasma xglucose xlevel xgreater
xthan x140 xmg/dL x(7.8 xmmol/L) xon xtwo xseparate xoccasions xare xall xdiagnostic xof xdiabetes xmellitus.
xThe xtotal xcholesterol xshould xbe xless xthan x200 xmg/dL x(5.2 xmmol/L). xConfirmation xof xthis xclient's
xresults xis xneeded xto xensure xappropriate xdiagnosis xand xtherapy. x
x
Levothyroxine xsodium xis xprescribed xfor xa xclient xwith xhypothyroidism, xand xthe xnurse xprovides
xinformation xto xthe xclient xabout xthe xmedication. xWhich xoccurrences xdoes xthe xnurse xtell xthe xclient
xto xreport xto xthe xhealth xcare xprovider? xSelect xall xthat xapply. x- xCORRECT xANSWER x-Chest xpain x x
Palpitations x
Rapid xheart xrate x
Rationale: xThe xclient xtaking xlevothyroxine xsodium xmay xhave xmanifestations xof xhypothyroidism xif xthe
xdosage xis xinadequate xor xmay xexperience xmanifestations xof xhyperthyroidism xif xthe xdosage xis xtoo
xhigh. xThyroid xpreparations xincrease xmetabolic xrate, xoxygen xdemands, xand xdemands xon xthe xheart,
xwhich xmay xresult xin xangina xand xcardiac xdysrhythmias. xThe xclient xshould xbe xinstructed xto xreport
xchest xpain, xpalpitations, xor xa xrapid xheart xrate ximmediately. xLethargy, xconstipation, xand xweight xgain
xare xsymptoms xof xhypothyroidism, xwhich xshould ximprove xwith xmedication xtherapy x(e.g.,
xlevothyroxine xsodium). x
x
, A xnurse xis xdeveloping xa xplan xof xcare xfor xan xolder xclient xwith xdiabetic xneuropathy xof xthe xlower
xextremities xresulting xfrom xtype x2 xdiabetes xmellitus. xWhich xproblem xdoes xthe xnurse xrecognize xas
xthe xhighest xpriority xfor xthis xclient? x- xCORRECT xANSWER x-Increased xrisk xfor xinjury x
Rationale: xThe xclient xwith xdiabetic xneuropathy xof xthe xlower xextremities xhas xa xdiminished xsensation
xin xthe xlegs xand xfeet. xThis xclient xis xat xrisk xfor xtissue xinjury xand xfor xfalls xas xa xresult xof xthis xnervous
xsystem ximpairment. xTherefore xthe xhighest xpriority xnursing xproblem xis xincreased xrisk xfor xinjury.
xIncreased xrisk xof xdepression xand xchange xin xbody ximage xare xmore xpsychosocial xin xnature xand, xas
xsuch, xare xsecondary xneeds. xA xlower xlevel xof xphysical xactivity xmay xbe xa xproblem xbut xis xnot xthe
xpriority. x
x
The xnurse xis xteaching xa xclient xwith xnewly xdiagnosed xdiabetes xmellitus xwho xhas xbeen xprescribed
xNPH xinsulin xhow xto xrecognize xthe xsigns xof xhypoglycemia. xThe xclient xstates xthat xhe xmust xlook xfor
xcertain xsigns xand xsymptoms xin xthe xlate xafternoon, xindicating xto xthe xnurse xthat xhe xhas xunderstood
xthe xinstructions. x
What xare xthese xsigns xand xsymptoms? xSelect xall xthat xapply. x- xCORRECT xANSWER x-Shakiness x
Blurred xvision x
Feelings xof xhunger x
Rationale: xThe xclient xtaking xNPH xinsulin xexperiences xpeak xmedication xeffects x6 xto x12 xhours xafter
xadministration. xWhen xthe xmedication's xaction xpeaks, xthe xclient xis xat xrisk xof xhypoglycemia xif xfood
xintake xis xinsufficient. xThe xnurse xteaches xthe xclient xto xbe xalert xfor xsigns xand xsymptoms xof
xhypoglycemia, xincluding xanxiety, xconfusion, xdifficulty xconcentrating, xblurred xvision, xcold xsweats,
xheadache, xincreased xpulse, xshakiness, xand xhunger. xThe xother xoptions xare xsigns xand xsymptoms xof
xhyperglycemia x
x
Glargine xinsulin xis xprescribed xfor xa xclient xwith xtype x1 xdiabetes xmellitus. xWhat xdoes xthe xnurse xtell
xthe xclient xabout xthis xtype xof xinsulin? xSelect xall xthat xapply x- xCORRECT xANSWER x-It xdoes xnot xhave xa
xpeak xeffect. x x
It xis xusually xgiven xonce xdaily, xat xbedtime. x x
It xusually xhas xa x24-hour xduration xof xaction x
Rationale: xGlargine xinsulin, xa xlong-acting xbasal xinsulin xanalog, xhas xan xonset xof xaction xof x1 xto x2
xhours, xwith xno xpeak xeffect, xand xa xduration xof xaction xof xmore xthan x24 xhours. xIt xis xusually xgiven
xonce xdaily, xpreferably xat xbedtime. xGlargine xinsulin xmay xnot xbe xmixed xin xa xsyringe xwith xother
xinsulin. x
x
x x x x
HEALTH NURSING EXAM QUESTIONS WITH RATIONALES
x x x x x x
x
A xnurse xis xmonitoring xa xclient xwho xis xtaking xspironolactone xfor xthe xtreatment xof xhypertension.
xWhich xfindings xdenote xadverse xeffects xof xthe xmedication? xSelect xall xthat xapply. x- xCORRECT
xANSWER x-Tall xT xwaves x
Prolonged xPR xinterval x
Hyperactive xbowel xsounds x
Rationale: xSpironolactone xis xa xpotassium-sparing xdiuretic. xPotassium-sparing xdiuretics xcan xcause
xhyperkalemia. xCardiovascular xmanifestations xof xhyperkalemia xinclude xtall xT xwaves, xwidened xQRS
xcomplexes, xprolonged xPR xintervals, xand xflat xP xwaves. xOther xcardiovascular xmanifestations xinclude
xan xirregular xheart xrate, xdecreased xblood xpressure, xand xectopic xheartbeats. xMuscle xtwitches xoccur
xin xhyperkalemia. xHyperactive xbowel xsounds xand xdiarrhea xalso xoccur xin xhyperkalemia. xConstipation,
xhyporeflexia, xand xshallow xrespirations xare xsigns xof xhypokalemia. x
x
A xnurse xis xproviding xdietary xinstructions xto xa xclient xwith xchronic xobstructive xpulmonary xdisease
x(COPD) xwho xis xexperiencing xa xloss xof xappetite xand xcomplains xof xfeeling x"too xfull xto xeat." xWhat
xdoes xthe xnurse xencourage xthe xclient xto xdo? xSelect xall xthat xapply. x- xCORRECT xANSWER x-Avoid
xdrinking xfluids xbefore xand xduring xmeals x
Select xfoods xthat xare xeasy xto xchew xand xare xnot xgas xforming x
Rationale: xCOPD xis xa xprogressive xand xirreversible xcondition xcharacterized xby xdiminished xinspiratory
xand xexpiratory xcapacity xof xthe xlungs. xInstruct xthe xclient xwho xcomplains xof xfeeling xtoo xfull xto xeat,
xto xavoid xdrinking xfluids xbefore xand xduring xthe xmeal. xDry xfoods xsuch xas xcrackers xstimulate
xcoughing; xfoods xsuch xas xmilk xand xchocolate xmay xincrease xthe xthickness xof xsaliva xand xsecretions.
xCheese xis xconstipating xand xshould xalso xbe xavoided xby xthe xclient. xThe xnurse xshould xalso xteach xthe
xclient xabout xfoods xthat xare xeasy xto xchew xand xdo xnot xencourage xthe xformation xof xgas; xfor xthis
xreason, xbroccoli, xwhich xis xa xgas-forming xfood, xshould xbe xavoided. x
x
A xtuberculin xskin xtest x(TST) xis xadministered xto xa xclient xwith xa xdiagnosis xof xHIV xinfection. xForty-eight
xhours xafter xadministration, xthe xnurse xchecks xthe xtest xsite x(see ximage). x- xCORRECT xANSWER x-
Positive x
Rationale: xThe xtuberculin, xor xTST, xtest xis xa xreliable xdeterminant xof xtuberculosis x(TB) xinfection. xA
xreaction xmeasuring x5 xmm xor xmore xin xdiameter xis xconsidered xpositive xin xa xclient xwith xHIV
xinfection. xA xreaction xmeasuring x10 xmm xor xmore xin xdiameter xis xconsidered xpositive xin xa xnon-
immunosuppressed xclient. xIn xthis xinstance, xthe xarea xof xinduration xmeasures x9 xmm, xindicating xa
,positive xreaction. xA xpositive xreaction xdoes xnot xmean xthat xactive xdisease xis xpresent, xbut xit xdoes
x
indicate xexposure xto xTB xor xthe xpresence xof xinactive x(dormant) xdisease. x
x
x
A xnurse xis xinterpreting xa xcentral xvenous xpressure x(CVP) xreading xfrom xa xclient xin xwhom xright
xventricular xfailure xhas xbeen xdiagnosed. xFrom xthis xdiagnosis, xthe xnurse xwould xexpect xthat xthe xmost
xlikely xresult xis xa xpressure xof x- xCORRECT xANSWER x-14 xcm xH2O x
Rationale: xCVP xmeasurements xare xused xto xmonitor xblood xvolume xand xthe xadequacy xof xvenous
xreturn xto xthe xheart. xThe xCVP xmeasures xpressures xfrom xthe xright xatrium xor xcentral xveins. xThe
xnormal xCVP xis x7 xto x12 xcm xH2O. xAn xincreased xCVP xreading xmay xindicate xright xventricular xfailure. xA
xlow xCVP xreading xmay xindicate xhypovolemia. xA xreading xof x4 xcm xH2O xis xlow. xReadings xof x8 xand x11
xcm xH2O xare xnormal. xA xreading xof x14 xcm xH2O xis xincreased. x
x
A xnurse xis xcaring xfor xa xclient xwho xhas xjust xundergone xthyroidectomy. xWhich xtechnique xis xthe xbest
xway xfor xthe xnurse xto xassess xthe xsurgical xsite xfor xbleeding? x- xCORRECT xANSWER x-Checking xfor
xmoisture xon xthe xback xof xthe xdressing xover xthe xclient's xneck xand xshoulders x
Rationale: xThyroid xsurgery xmay xbe xcomplicated xby xhemorrhage, xrespiratory xdistress, xparathyroid
xgland xinjury x(resulting xin xhypocalcemia xand xtetany), xdamage xto xthe xlaryngeal xnerves, xand xthyroid
xstorm. xHemorrhage xis xmost xlikely xduring xthe x24 xhours xafter xsurgery. xIf xthe xclient xis xbleeding xafter
xsurgery, xgravity xwill xcause xthe xblood xto xseep xdown xthe xsides xof xthe xdressing xand xdrain xonto xthe
xunderlying xbed xlinens xeven xas xthe xtop xof xthe xdressing xremains xclean xand xdry. xAsking xthe xclient
xwhether xthe xdressing xfeels xwet xand xreplacing xthe xdry xsterile xdressing xevery x2 xhours xare xnot xthe
xbest xactions. xReplacing xthe xdressing xfrequently xwhen xit xis xnot xwarranted xcould xalso xincrease xthe
xrisk xof xinfection. x
x
A xclient xwho xsustained xa xmajor xburn xinjury xis xbeginning xto xtake xan xoral xdiet xagain. xWhich
xbetween-meal xmenu xselections xmeet xthe xclient's xneeds xfor xwound xhealing xand xtissue xrepair?
xSelect xall xthat xapply. x- xCORRECT xANSWER x-Whole-milk xshake xand xgranola x
x Baked xpotato xtopped xwith xcheese x
x Cheese xand xwhole-wheat xcrackers x
Rationale: xTo xfacilitate xhealing xand xmeet xcontinued xhigh xmetabolic xneeds, xthe xclient xwith xa xmajor
xburn xshould xeat xa xdiet xhigh xin xcalories, xprotein, xand xcarbohydrates. xThis xtype xof xdiet xalso xkeeps
xthe xclient xin xpositive xnitrogen xbalance. xFoods xsuch xas xmilkshakes, xgranola, xcheese, xand xwhole-
wheat xproducts xare xacceptable xchoices. xThough xfresh xfruits xand xvegetables xand xskim xmilk xare xhigh
xin xnutrients, xhighercalorie xfoods, xincluding xversions xof xdairy xproducts xprepared xwith xwhole xmilk,
xare xpreferable xin xthis xsituation. x
x
,A xclient xis xfound xto xhave xhypoparathyroidism. xWhich xnutritional xsupplement xdoes xthe xnurse,
xteaching xthe xclient xabout xmeasures xto xmanage xthe xdisorder, xtell xthe xclient xto xtake xon xa xdaily
xbasis? x- xCORRECT xANSWER x-Calcium xcarbonate xwith xvitamin xD x
Rationale: xHypoparathyroidism xis xan xendocrine xdisorder xin xwhich xparathyroid xfunction xis xdecreased.
xThe xclient xwith xhypoparathyroidism xis xlikely xto xhave xlow xcalcium xand xhigh xphosphate xlevels xand
xshould xconsume xa xdiet xhigh xin xcalcium xbut xlow xin xphosphorus. xAdditionally, xthe xgenerally xused
xtreatment xis xcalcium xsupplementation x(either xas xcalcium xcarbonate xor xcalcium xcitrate) xcoupled xwith
xvitamin xD x
supplementation. xVitamin xC xsupplementation xis xnot xa xtreatment xmeasure xfor xthis xdisorder.
xBetacarotene xis xincorrect, xbecause xa xclient xwith xhypoparathyroidism xtypically xhas xan xincreased
xphosphorus xlevel x
x
A xnurse xparticipating xin xa xfree xhealth xscreening xat xthe xlocal xmall xobtains xa xrandom xblood xglucose
xlevel xof x190 xmg/dL x(10.6 xmmol/L) xand xa xtotal xcholesterol xlevel xof x210 xmg/dL x(5.4 xmmol/L) xin xan
xotherwise xhealthy xclient. xWhat xshould xthe xnurse xtell xthe xclient xto xdo xnext? x- xCORRECT xANSWER x-
Call xhis xhealth xcare xprovider xto xhave xthese xvalues xrechecked xas xsoon xas xpossible x
Rationale: xAdult xdiabetes xmellitus xmay xbe xdiagnosed xon xthe xbasis xof xsymptoms x(e.g., xpolydipsia,
xpolyuria, xpolyphagia) xor xlaboratory xvalues. xAn xabnormal xglucose xtolerance xtest, xa xrandom xplasma
xglucose xlevel xgreater xthan x200 xmg/dL x(11.1 xmmol/L), xand xa xfasting xplasma xglucose xlevel xgreater
xthan x140 xmg/dL x(7.8 xmmol/L) xon xtwo xseparate xoccasions xare xall xdiagnostic xof xdiabetes xmellitus.
xThe xtotal xcholesterol xshould xbe xless xthan x200 xmg/dL x(5.2 xmmol/L). xConfirmation xof xthis xclient's
xresults xis xneeded xto xensure xappropriate xdiagnosis xand xtherapy. x
x
Levothyroxine xsodium xis xprescribed xfor xa xclient xwith xhypothyroidism, xand xthe xnurse xprovides
xinformation xto xthe xclient xabout xthe xmedication. xWhich xoccurrences xdoes xthe xnurse xtell xthe xclient
xto xreport xto xthe xhealth xcare xprovider? xSelect xall xthat xapply. x- xCORRECT xANSWER x-Chest xpain x x
Palpitations x
Rapid xheart xrate x
Rationale: xThe xclient xtaking xlevothyroxine xsodium xmay xhave xmanifestations xof xhypothyroidism xif xthe
xdosage xis xinadequate xor xmay xexperience xmanifestations xof xhyperthyroidism xif xthe xdosage xis xtoo
xhigh. xThyroid xpreparations xincrease xmetabolic xrate, xoxygen xdemands, xand xdemands xon xthe xheart,
xwhich xmay xresult xin xangina xand xcardiac xdysrhythmias. xThe xclient xshould xbe xinstructed xto xreport
xchest xpain, xpalpitations, xor xa xrapid xheart xrate ximmediately. xLethargy, xconstipation, xand xweight xgain
xare xsymptoms xof xhypothyroidism, xwhich xshould ximprove xwith xmedication xtherapy x(e.g.,
xlevothyroxine xsodium). x
x
, A xnurse xis xdeveloping xa xplan xof xcare xfor xan xolder xclient xwith xdiabetic xneuropathy xof xthe xlower
xextremities xresulting xfrom xtype x2 xdiabetes xmellitus. xWhich xproblem xdoes xthe xnurse xrecognize xas
xthe xhighest xpriority xfor xthis xclient? x- xCORRECT xANSWER x-Increased xrisk xfor xinjury x
Rationale: xThe xclient xwith xdiabetic xneuropathy xof xthe xlower xextremities xhas xa xdiminished xsensation
xin xthe xlegs xand xfeet. xThis xclient xis xat xrisk xfor xtissue xinjury xand xfor xfalls xas xa xresult xof xthis xnervous
xsystem ximpairment. xTherefore xthe xhighest xpriority xnursing xproblem xis xincreased xrisk xfor xinjury.
xIncreased xrisk xof xdepression xand xchange xin xbody ximage xare xmore xpsychosocial xin xnature xand, xas
xsuch, xare xsecondary xneeds. xA xlower xlevel xof xphysical xactivity xmay xbe xa xproblem xbut xis xnot xthe
xpriority. x
x
The xnurse xis xteaching xa xclient xwith xnewly xdiagnosed xdiabetes xmellitus xwho xhas xbeen xprescribed
xNPH xinsulin xhow xto xrecognize xthe xsigns xof xhypoglycemia. xThe xclient xstates xthat xhe xmust xlook xfor
xcertain xsigns xand xsymptoms xin xthe xlate xafternoon, xindicating xto xthe xnurse xthat xhe xhas xunderstood
xthe xinstructions. x
What xare xthese xsigns xand xsymptoms? xSelect xall xthat xapply. x- xCORRECT xANSWER x-Shakiness x
Blurred xvision x
Feelings xof xhunger x
Rationale: xThe xclient xtaking xNPH xinsulin xexperiences xpeak xmedication xeffects x6 xto x12 xhours xafter
xadministration. xWhen xthe xmedication's xaction xpeaks, xthe xclient xis xat xrisk xof xhypoglycemia xif xfood
xintake xis xinsufficient. xThe xnurse xteaches xthe xclient xto xbe xalert xfor xsigns xand xsymptoms xof
xhypoglycemia, xincluding xanxiety, xconfusion, xdifficulty xconcentrating, xblurred xvision, xcold xsweats,
xheadache, xincreased xpulse, xshakiness, xand xhunger. xThe xother xoptions xare xsigns xand xsymptoms xof
xhyperglycemia x
x
Glargine xinsulin xis xprescribed xfor xa xclient xwith xtype x1 xdiabetes xmellitus. xWhat xdoes xthe xnurse xtell
xthe xclient xabout xthis xtype xof xinsulin? xSelect xall xthat xapply x- xCORRECT xANSWER x-It xdoes xnot xhave xa
xpeak xeffect. x x
It xis xusually xgiven xonce xdaily, xat xbedtime. x x
It xusually xhas xa x24-hour xduration xof xaction x
Rationale: xGlargine xinsulin, xa xlong-acting xbasal xinsulin xanalog, xhas xan xonset xof xaction xof x1 xto x2
xhours, xwith xno xpeak xeffect, xand xa xduration xof xaction xof xmore xthan x24 xhours. xIt xis xusually xgiven
xonce xdaily, xpreferably xat xbedtime. xGlargine xinsulin xmay xnot xbe xmixed xin xa xsyringe xwith xother
xinsulin. x
x
