Term
A pt is brought to the ED by paramedics. The pt is a type 2 diabetic
and is experiencing HHS. The nurse should identify what
components of HHS? Select all that apply:
a. leukocytosis
b. glycosuria
c. dehydration
d. hypernatremia
e. hyperglycemia
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D A, C, D
C, E B, C, D, E
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, 2 of 50
Term
Client w/ pituitary tumor developed SIADH. Which intervention
should the nurse implement?
a. assess for dehydration and monitor BG level
b. assess for n/v & weigh daily
c. monitor potassium level & encourage fluid intake
d. administer vasopressin IV and conduct fluid deprivation test
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B C
A D
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3 of 50
Term
You are developing a care plan for a pt w/ Cushing syndrome. What
nursing diagnosis would have the highest priority in this care plan?
a. risk for injury r/t weakness
b. ineffective breathing pattern r/t muscle weakness
c. risk for loneliness r/t disturbed body image
d. autonomic dysreflexia r/t neurologic changes
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, D B
A C
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4 of 50
Term
The most recent blood work of a pt with a longstanding diagnosis of
type 1 diabetes has shown the presence of microalbuminuria. What is
the nurses most appropriate action?
a. teach pt about actions to slow progression of nephropathy
b. ensure that pt receives a comprehensive assessment of liver
function
c. determine whether pt has been using expired insulin
d. administer a fluid challenge and have test repeated
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B C
D A
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5 of 50
, Term
Nurse performing an assessment on a client w/ pheochromocytoma.
Which assessment data would indicate potential complication with
this disease?
a. urinary output of 50ml/h
b. coagulation time of 5 mins
c. HR that is 90bpm & irregular
d. BUN of 20 mg/dL
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B C
D A, D
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6 of 50
Term
The nurse caring for a pt w/ Cushing syndrome is describing the
dexamethasone suppression test scheduled for tomorrow/ What
does the nurse explain that this test will involve?
a. administration of dexamethasone orally, followed by a plasma
cortisol level every hr for 3 hrs
b. administration of dexamethasone IV, followed by an x-ray of the
adrenal glands
c. administration of dexamethasone orally at 11pm, and a plasma
cortisol level at 8am the next morning