Nursing Elites

1. Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?

• A. Antidiuretic hormone (ADH)
• B. Thyroid-stimulating hormone (TSH)
• C. Follicle-stimulating hormone (FSH)
• D. Luteinizing hormone (LH)

Correct answer: A

Rationale: Diabetes insipidus is a condition characterized by a deficiency of antidiuretic hormone (ADH). ADH plays a crucial role in regulating water balance by controlling the amount of water reabsorbed by the kidneys. Options B, C, and D are incorrect as they are not associated with diabetes insipidus. TSH (thyroid-stimulating hormone) is responsible for regulating thyroid function, while FSH (follicle-stimulating hormone) and LH (luteinizing hormone) are involved in reproductive functions.

2. Which of the following statements should be included in the teaching to a client about a do-not-resuscitate order (DNR)?

• A. When a heart ceases to beat, the client is pronounced clinically dead.
• B. Physicians are required to write DNR orders.
• C. A DNR order can be written after discussion with the client and family.
• D. A court decision is needed for a DNR.

Correct answer: C

Rationale: The correct statement to include in teaching a client about a do-not-resuscitate (DNR) order is that it can be written after discussion with the client and family. This involves ensuring that the client and their family understand the implications and make an informed decision. Choice A is incorrect as pronouncing clinical death is not directly related to discussing a DNR order. Choice B is incorrect as while physicians typically write DNR orders, it is not a strict requirement. Choice D is incorrect as a court decision is not typically required for a DNR order; it is a decision made by the client with input from healthcare providers and family members.

3. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

• A. Weight loss
• B. Flat neck and hand veins
• C. An increase in blood pressure
• D. A decreased central venous pressure (CVP)

Correct answer: C

Rationale: An increase in blood pressure is a common sign of fluid volume excess in clients with congestive heart failure due to the increased amount of fluid in the vascular system. Weight loss (Choice A) is not typically associated with fluid volume excess. Flat neck and hand veins (Choice B) are signs of fluid volume deficit, not excess. A decreased central venous pressure (CVP) (Choice D) is not expected in a client with fluid volume excess.

4. A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is:

• A. 2-4 hours after administration
• B. 6-14 hours after administration
• C. 16-18 hours after administration
• D. 18-24 hours after administration

Correct answer: B

Rationale: The correct answer is B: 6-14 hours after administration. NPH insulin has an onset of action within 1-2 hours, a peak action at 6-14 hours, and a duration of action of 16-24 hours. The peak action period, which is when the risk of hypoglycemia is highest, falls between 6-14 hours after administration. Choices A, C, and D are incorrect because they do not align with the typical action profile of NPH insulin.

5. During a physical assessment of a client with type 2 DM, a nurse notes the following findings: fasting blood glucose of 120 mg/dl, temperature of 101°F, pulse 88 bpm, respirations 22/min, and BP 140/84 mmHg. Which finding should concern the nurse the most?

• A. Pulse
• B. BP
• C. Respiration
• D. Temperature

Correct answer: D

Rationale: The correct answer is 'Temperature.' A temperature of 101°F indicates a fever, which can be a sign of infection. In individuals with diabetes, infections can lead to significant complications and affect blood glucose control. Monitoring and addressing infections promptly are crucial in individuals with diabetes to prevent worsening of their condition. Choice A, 'Pulse,' is within the normal range (60-100 bpm) and does not indicate an immediate concern. Choice B, 'BP,' while slightly elevated, is not as acutely concerning as an elevated temperature in this scenario. Choice C, 'Respiration,' falls within the normal range (12-20 breaths/min) and is not the most concerning finding among the options provided.

Similar Questions