PNR 206/PNR206 Exam 3 V2 | Medical-
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A client with type 1 diabetes mellitus presents to the emergency department with deep,
rapid respirations and a blood glucose level of 480 mg/dL. Which acid-base imbalance does
the nurse identify?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
Correct Answer: C
Expert Explanation: The client is exhibiting signs of diabetic ketoacidosis (DKA), which
occurs when the body breaks down fat for energy, producing acidic ketones. This process
results in a decrease in serum pH and bicarbonate levels, leading to metabolic acidosis. The
deep, rapid respirations known as Kussmaul breathing represent the body’s attempt to
blow off carbon dioxide to compensate for the acidity.
2. A nurse is providing discharge instructions to a client with Addison’s disease. Which
information regarding medication management is most critical?
A. Never abruptly stop taking the prescribed glucocorticoids.
,B. Decrease sodium intake while taking steroids.
C. Take medications only when feeling symptomatic.
D. Avoid taking the medication with food.
Correct Answer: A
Expert Explanation: Abrupt cessation of glucocorticoids in a client with Addison’s disease
can precipitate an adrenal crisis, which is a life-threatening emergency. The adrenal glands
in these clients do not produce enough endogenous cortisol to sustain life during stress.
Clients must be taught to carry an emergency kit and understand that life-long hormone
replacement is necessary.
3. Which clinical manifestation should the nurse expect to find in a client diagnosed with
Cushing’s syndrome?
A. Weight loss and hypotension
B. Moon face and abdominal striae
C. Hypoglycemia and hyperkalemia
D. Increased muscle mass in the extremities
Correct Answer: B
Expert Explanation: Cushing’s syndrome is characterized by an overproduction of
cortisol, which leads to fat redistribution. Common signs include a rounded ‘moon face,’ a
,‘buffalo hump’ on the back, and purple striae on the abdomen. These physical changes are
classic indicators of chronic glucocorticoid excess often seen in this patient population.
4. A client is diagnosed with hyperthyroidism (Graves’ disease). Which assessment finding
requires immediate intervention by the nurse?
A. An increase in temperature to 102°F (38.9°C)
B. The presence of protruding eyes (exophthalmos)
C. A resting heart rate of 105 beats per minute
D. Reports of feeling hot and being restless
Correct Answer: A
Expert Explanation: A significant rise in temperature in a client with hyperthyroidism
may indicate the onset of thyroid storm, a life-threatening hypermetabolic state. Thyroid
storm requires urgent medical attention to prevent cardiac failure and death. While
exophthalmos and tachycardia are common symptoms of Graves’ disease, they are not as
immediately life-threatening as a sudden fever.
5. The nurse is caring for a client with Diabetes Insipidus (DI). Which laboratory result is
consistent with this diagnosis?
A. Urine specific gravity of 1.035
B. Serum sodium of 130 mEq/L
C. Blood glucose of 250 mg/dL
, D. Urine specific gravity of 1.002
Correct Answer: D
Expert Explanation: Diabetes Insipidus is caused by a deficiency of antidiuretic hormone
(ADH), leading to the excretion of large volumes of dilute urine. A urine specific gravity of
1.002 is significantly lower than the normal range (1.005–1.030), indicating highly dilute
urine. In contrast, SIADH would present with a high specific gravity and low serum sodium.
6. A client with SIADH is being treated for hyponatremia. Which nursing intervention is a
priority for this client?
A. Increasing fluid intake to 3000 mL/day
B. Restricting fluid intake as prescribed
C. Administering a hypotonic IV solution
D. Encouraging the consumption of low-sodium foods
Correct Answer: B
Expert Explanation: In Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the
body retains too much water, which dilutes serum sodium levels. Fluid restriction is the
primary treatment to prevent further dilution and manage symptoms of hyponatremia.
Monitoring intake and output along with daily weights is essential for evaluating the
effectiveness of this intervention.
Surgical Nursing II Q&A with Rationale |
Fortis College
1. A client with type 1 diabetes mellitus presents to the emergency department with deep,
rapid respirations and a blood glucose level of 480 mg/dL. Which acid-base imbalance does
the nurse identify?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
Correct Answer: C
Expert Explanation: The client is exhibiting signs of diabetic ketoacidosis (DKA), which
occurs when the body breaks down fat for energy, producing acidic ketones. This process
results in a decrease in serum pH and bicarbonate levels, leading to metabolic acidosis. The
deep, rapid respirations known as Kussmaul breathing represent the body’s attempt to
blow off carbon dioxide to compensate for the acidity.
2. A nurse is providing discharge instructions to a client with Addison’s disease. Which
information regarding medication management is most critical?
A. Never abruptly stop taking the prescribed glucocorticoids.
,B. Decrease sodium intake while taking steroids.
C. Take medications only when feeling symptomatic.
D. Avoid taking the medication with food.
Correct Answer: A
Expert Explanation: Abrupt cessation of glucocorticoids in a client with Addison’s disease
can precipitate an adrenal crisis, which is a life-threatening emergency. The adrenal glands
in these clients do not produce enough endogenous cortisol to sustain life during stress.
Clients must be taught to carry an emergency kit and understand that life-long hormone
replacement is necessary.
3. Which clinical manifestation should the nurse expect to find in a client diagnosed with
Cushing’s syndrome?
A. Weight loss and hypotension
B. Moon face and abdominal striae
C. Hypoglycemia and hyperkalemia
D. Increased muscle mass in the extremities
Correct Answer: B
Expert Explanation: Cushing’s syndrome is characterized by an overproduction of
cortisol, which leads to fat redistribution. Common signs include a rounded ‘moon face,’ a
,‘buffalo hump’ on the back, and purple striae on the abdomen. These physical changes are
classic indicators of chronic glucocorticoid excess often seen in this patient population.
4. A client is diagnosed with hyperthyroidism (Graves’ disease). Which assessment finding
requires immediate intervention by the nurse?
A. An increase in temperature to 102°F (38.9°C)
B. The presence of protruding eyes (exophthalmos)
C. A resting heart rate of 105 beats per minute
D. Reports of feeling hot and being restless
Correct Answer: A
Expert Explanation: A significant rise in temperature in a client with hyperthyroidism
may indicate the onset of thyroid storm, a life-threatening hypermetabolic state. Thyroid
storm requires urgent medical attention to prevent cardiac failure and death. While
exophthalmos and tachycardia are common symptoms of Graves’ disease, they are not as
immediately life-threatening as a sudden fever.
5. The nurse is caring for a client with Diabetes Insipidus (DI). Which laboratory result is
consistent with this diagnosis?
A. Urine specific gravity of 1.035
B. Serum sodium of 130 mEq/L
C. Blood glucose of 250 mg/dL
, D. Urine specific gravity of 1.002
Correct Answer: D
Expert Explanation: Diabetes Insipidus is caused by a deficiency of antidiuretic hormone
(ADH), leading to the excretion of large volumes of dilute urine. A urine specific gravity of
1.002 is significantly lower than the normal range (1.005–1.030), indicating highly dilute
urine. In contrast, SIADH would present with a high specific gravity and low serum sodium.
6. A client with SIADH is being treated for hyponatremia. Which nursing intervention is a
priority for this client?
A. Increasing fluid intake to 3000 mL/day
B. Restricting fluid intake as prescribed
C. Administering a hypotonic IV solution
D. Encouraging the consumption of low-sodium foods
Correct Answer: B
Expert Explanation: In Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the
body retains too much water, which dilutes serum sodium levels. Fluid restriction is the
primary treatment to prevent further dilution and manage symptoms of hyponatremia.
Monitoring intake and output along with daily weights is essential for evaluating the
effectiveness of this intervention.
