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A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription?
1.Endotracheal intubation 2.100 units of NPH insulin 3.Intravenous infusion of normal saline
4.Intravenous infusion of
sodium bicarbonate
Intravenous infusion of
normal saline
The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS.
An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?
_- It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals.
- It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels.
- It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream.
- It administers a small continuous dose of short-duration insulin subcutaneously. The client can self- administer an additional bolus dose from the pump before each meal._
It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.
An insulin pump provides a small continuous dose of short-duration (rapid- or short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.
1.Incre ase in pH 2.Com atose state 3.Deep, rapid breathi ng 4.Decr eased urine output 5.Elevated blood glucose level
2.Co matos e state 3.Dee p, rapid breat hing 5.Elevated blood glucose level
Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the
body breaks down fat as a secondary source of energy. Ketones, which are acid byproducts of fat metabolism, build up and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply.
_- P ol yu ri a
Sh_
Convey empathy, trust, and respect toward the client.
Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention and does not address the source of the client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs to be managed before meaningful client education can occur.
The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?
_- "I will stop taking my insulin if I'm too sick to eat."
- "I will decrease my insulin dose during times of illness."
- "I will adjust my insulin dose according to the level of glucose in my urine."
- "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."_
"I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."
During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL (14.2 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication?
1.An ampule of 50% dextrose 2.NPH insulin subcutaneou sly 3.IV fluids containing dextrose 4.Phenytoin for the prevention of seizures
IV fluids containing dextrose
Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV
infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.
The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?
- P o l y u r i a 2. D i a p h o r e s i s 3. P e d a l e d e m a
4.Decreas
ed
respiratory
head of the bed. 2.Test the drainage for glucose. 3.Obtain a culture of the drainage.
4.Continue to
observe the
drainage. Test the
drainage for
glucose.
After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply.
1.Initiate an infusion of 3% NaCl. 2.Administer intravenous furosemide. 3.Restrict fluids to 800 mL over 24 hours.
4.Elevate the head of the bed to high Fowler's. 5.Administer a vasopressin antagonist as prescribed.
1.Initiate an infusion of 3% NaCl. 3.Restrict fluids to 800 mL over 24 hours. 5.Administer a vasopressin antagonist as prescribed
Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia. Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L ( mmol/L). An intravenous (IV) infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as prescribed and an infusion pump must be used. Fluid restriction is a useful
strategy aimed at correcting dilutional hyponatremia. Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide may be used to treat extravascular volume and dilutional hyponatremia in SIADH, but it is only safe to use if the serum sodium is at least 125 mEq/L (125 mmol/L). When furosemide is used, potassium supplementation should also occur and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the client with SIADH. Maximizing venous return helps to avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed.
A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?
1.Warm the client. 2.Maintai n a patent airway. 3.Administer thyroid hormone. 4.Administer fluid replacement.
Maintain a patent airway.
Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.
The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?
- Correct the acidosis.
- Administer 5% dextrose intravenously. 3.Apply a monitor for an electrocardiogram.
4.Administer short-duration
insulin intravenously.
Administer short-duration
insulin intravenously.
Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline
- 3 B o n e p a i n 4 N e r v o u s n e s s 5 W e i g h t g a i n 1 P o l y u r i a
B o n e p a i n
The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain. Options 2, 4, and 5 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.
The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching?
- "I should limit my fluids to 1 liter per day."
- "I should use my treadmill or go for walks daily."
- "I should follow a moderate-calcium, high-fiber diet."
- "My alendronate helps to keep calcium from coming
out of my bones." "I should limit my fluids to 1 liter
per day."
In hyperparathyroidism, clients experience excess parathyroid hormone (PTH) secretion. A role of PTH in the body is to maintain serum calcium homeostasis. When PTH levels are high, there is excess bone resorption
(calcium is pulled from the bones). In clients with elevated serum calcium levels, there is a risk of nephrolithiasis. One to 2 liters of fluids daily should be encouraged to protect the kidneys and decrease the risk of nephrolithiasis. Moderate physical activity, particularly weight-bearing activity, minimizes bone resorption and helps to protect against pathological fracture. Walking, as an exercise, should be encouraged in the client with hyperparathyroidism. Clients should follow a moderate-calcium, high-fiber diet. Even though serum calcium is already high, clients should follow a moderate-calcium diet because a low- calcium diet will surge PTH. Calcium causes constipation, so a diet high in fiber is recommended. Alendronate is a bisphosphate that inhibits bone resorption. In bone resorption, bone is broken down and calcium is deposited into the serum.
A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply.
l c e m i a 5. H y p e r n a t r e m i a 1. H y p o t e n s i o n 3. H y p e r k a l e m i a
In Addison's disease, also known as adrenal insufficiency, destruction of the adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid
cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal insufficiency, occurs when there is extreme physical or emotional stress and lack of sufficient adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the catecholamines epinephrine and norepinephrine. Hypotension occurs when vascular tone is decreased and blood vessels cannot respond to epinephrine and norepinephrine. The role of aldosterone in the body is to support the blood pressure by holding salt and water and excreting potassium. When there is insufficient aldosterone, salt and water are lost and potassium builds up; this leads to hypotension from decreased vascular volume, hyponatremia, and hyperkalemia. The remaining options are not associated with Addisonian crisis.
The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.
- T r e m o r s 2. A n o r e x i a 3. I r r i t a b i l i t y 4
s 3. I r r i t a b i l i t y 4. N e r v o u s n e s s
Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger.
The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?
1.A urinary output of 50 mL/hour 2.A coagulation time of 5 minutes 3.A heart rate that is 90 beats/minute and irregular
4.A blood urea nitrogen level of 20
mg/dL (7.1 mmol/L) A heart rate that
is 90 beats/minute and irregular
Pheochromocytoma is a catecholamine-producing tumor usually found in the adrenal medulla, but extraadrenal locations include the chest, bladder, abdomen, and brain; it is typically a benign tumor but can be malignant. Excessive amounts of epinephrine and norepinephrine are secreted. The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke,
kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hour is an adequate output. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) is a normal finding.
The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply.
- A n x i e t y 2. L e u k o c y t o s i s 3. C h v o s t e k ' s s i g n
4.Urinary output of 800 mL/hour
- T e m p e r a t u r e 4. B l o o d p r e s s u r e
Temperature
In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits.
The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.
T re m or s
W ei g ht
lo ss
F e el in g c ol d
L o ss of b o d y h ai r 5.Pe rsist ent letha rgy 6.Pu ffine ss of the face
Fe eli ng col d
Lo ss of bo dy hai r
Pe rsi ste nt let
