QuizAAA: July 2018

1. Client who takes supplemental calcium and iron
2. Client who is overweight and has elevated cholesterol
3. Client who prefers hard cheeses and whole milk
4. Client who prefers fruits and vegetables rather than meats

Answer: 2

Overweight clients put increased stress on the weight-bearing joints and are at more risk for hip, knee, and ankle problems. The other options are not risk factors, and taking supplemental calcium and eating dairy products would reduce the risk of fractures. (Ignatavicius, Workman, 7 ed., p. 1110.)

Which client would be at increased risk for musculoskeletal problems based on a nursing nutritional assessment?

Which client injury would the nurse expect to heal the most rapidly?

1. Fractured nose
2. Fractured tibia
3. Torn medial meniscus in the knee
4. Severely sprained wrist

Answer: 2

Bone tissue heals very quickly because of the process of self-healing also known as union. It is characterized by the following stages: fracture hematoma, granulation tissue, callus formation, ossification, consolidation, and remodeling. Injuries to cartilage, tendons, and ligaments are slower to heal because of decreased vascularity and circulation in these tissues. (Ignatavicius, Workman, 7 ed., p. 1144-1145.)

What would the nurse identify as the best pre procedure nursing intervention for a client who is scheduled for dual-energy x-ray absorptiometry (DEXA) testing?

1. Obtain vital signs before administering an oral sedative.
2. Check for allergy to iodine and shellfish.
3. Start a peripheral intravenous line.
4. Explain the procedure to the client.

Answer: 4

The best preprocedure nursing intervention for the noninvasive test of a dual-energy x-ray absorptiometry (DEXA) is client education, because the procedure is painless and noninvasive. The nurse should explain to the client to wear loose, comfortable clothing and avoid garments that have zippers, belts, or buttons that are made of metal. Objects such as keys or wallets that would be in the area being scanned should be removed. No preprocedure medications are administered, and contrast medium is not used. (Ignatavicius, Workman, 7 ed., p. 1123.)

Which diagnostic tools would the nurse identify as the most useful in evaluating undiagnosed skeletal and joint conditions?

1. X-Ray
2. MRI
3. CT scan
4. Myelogram

Answer: 1

X-ray films are very useful diagnostic tools and can be used to identify joint disruption, bone deformities, calcifications, bone deterioration, and fractures and are used to measure bone density. MRI uses a strong magnetic field and radio waves to diagnose conditions (three-dimensional view), especially problems in the joints and soft tissue injuries. A CT scan can be used to identify injuries of soft tissue, ligaments, tendons, and muscles. Obtaining a myelogram is an invasive procedure used to evaluate abnormalities of the spinal canal and cord. (Ignatavicius, Workman, 7 ed., p. 1114-1115.)

A 7-year-old boy is in the emergency department with a greenstick fracture of the ulna. How will the nurse explain the fracture to the parents?

1. The bone is broken across the growth plate.
2. There is a splintering of the bone on one side.
3. There is a separation of the bone at the fracture site.
4. The bone is broken into several fragments.

Answer: 2

Greenstick fracture refers to splintering of the bone, not a complete fracture. The name comes from the splintering effect in attempts to break a "green stick." It is a common fracture in children. A comminuted fracture (bone is broken into several fragments) has multiple bone fragments and is more common in adults. Greenstick fractures do not affect the growth plate and there is no bone separation. (Lewis 8 ed, p. 1590).

Which of the following statements by the client who has recently had a total hip replacement indicates that the client does not understand the mobility limitations?

1. "I should not bend down to put on shoes or socks."
2. "It is okay to cross my legs if I am sitting in a chair."
3. "I should put a pillow between my legs when lying on my side.
4. "I should not sit in low chairs or on toilet seats that are low."

Answer: 2

Clients with total hip replacement should not bring their operative leg across midline, which may result in a prosthesis dislocation. Clients should maintain abduction (pillow between legs) and use elevated toilet seats. Crossing the legs is adduction, which is contraindicated for this client.

A client with diabetes and a right below-the-knee amputation tells the nurse that he feels pain in the amputated leg, even though the leg is gone. The nurse's response is based on what information?

1. Phantom pain is experienced by most amputees; it will resolve without pain medication.
2. The client thinks he feels pain, but it is actually a response to his denial about the amputation.
3. The nurse cannot adequately assess the pain; therefore, medication cannot be given.
4. Phantom pain occurs when the nerve endings have not adjusted to the loss of the extremity, and the client should be offered pain medication.

Answer: 4

Phantom limb pain is real pain for the client and is common in amputees. Phantom pain can best be controlled by pain medication. It is important to respect a client's interpretation of the experience of pain and offer him or her pain medication. (Lewis 8 ed, p. 1612).

The nurse is planning care for a client with a herniated disc. What intervention is considered part of conservative treatment of herniated disc?

1. Left lateral Sims' position with bathroom privileges
2. Bed rest and methocarbamol (Robaxin) to decrease muscle spasms
3. Small incision in the spinal column to remove the disk
4. Daily physical therapy and ambulation with crutches

Answer: 2

Conservative treatment means without surgical intervention. The most common conservative therapy includes bed rest and a muscle relaxant. An incision into the spinal column is not considered conservative treatment. Increased mobility may aggravate the herniated disc condition. (Lewis 8 ed, p. 1629).

A client is placed in balanced traction with a Thomas splint and a Pearson attachment. What will the nursing care of a client in this type of traction include?

1. Assessing the groin area for signs of pressure
2. Preventing pressure at the heel of the affected side
3. Changing the compression bandages once a shift
4. Maintaining the bed in flat position to facilitate traction

Answer: 1

Balanced suspension traction with a Thomas splint is a type of skeletal traction that requires checking the groin area where the thigh is supported. The leg of the affected side is suspended off the bed, and the heel is usually not a problem. Because it is skeletal traction, there is no compression bandage. (deWit, 2 ed, p. 788, 798-799).

What is the priority nursing intervention in the care of a client in balanced suspension traction for a complete transverse fracture of the left femur?

1. Assessment of the pin site and movement of extremity distal to injury
2. Frequent checks regarding level of pain and sensation distal to the affected extremity
3. Maintaining abduction device between the legs to prevent external rotation of the affected leg
4. Increasing fluid intake to prevent the development of renal stone caused by urinary stasis

Answer: 2

Compartment syndrome is characterized by consistent pain and loss of sensation distal to the area of injury. The client can have an adequate peripheral pulse and still have a problem with compartmental syndrome. The client in balanced suspension traction has pins or wires exerting traction on the bone; pin site care is important, but evaluating for compartmental syndrome is a priority. Maintaining good fluid intake is also important, but assessing neurocirculatory status is more important. (Lewis 8 ed, p. 1591 & 1603).

Nursing care for the client in Buck's traction includes what measures?

1. Maintaining client in semi-Fowler's position to promote deep breathing
2. Checking the distal circulation of the affected leg
3. Turning the client every 2 hours to the unaffected side
4. Allowing the client to sit in a chair at the bedside

Answer: 2

The priority of care is to check the status of circulation distal to the area of injury. The client is generally kept in the supine position to promote straight pull on the traction; the client is not out of bed. Deep breathing is encouraged, but semi-Fowler's position does not facilitate the traction. (Lewis 8 ed, p. 1593 & 1599).

Nursing care for the client in Buck's traction includes what measures?

The nursing care plan for a 2-month-old infant in a left hip spica cast includes what nursing measures?

1. Palpating the left brachial artery and comparing it with the right
2. Checking cast for tightness by inserting fingers between skin and cast
3. Assessing for blanching of the skin in areas proximal to the casted left leg
4. Maintaining constant traction on the affected left leg

Answer: 2

A hip spica cast is used for the treatment of congenital hip dysplasia. Check the cast to make sure it is not too tight and constricting circulation by inserting a finger between the skin and cast. The child is not in traction with a hip spica cast and the arms are not being treated. The circulation is checked distal to the cast not proximal. (Hockenberry, Wilson, 9 ed p. 423).

What evaluation is important in the preoperative nursing assessment of a client with a severely herniated lumbar disk?

1. Movement and sensation in the lower extremities
2. Leg pain that radiates to both lower extremities
3. Reflexes in the upper extremities
4. Pupillary reaction to light

Answer: 1

The movement and sensation should be evaluated before surgery to serve as a baseline for comparison during the postoperative recovery period. Radiating leg pain is diagnostic of the condition, and assessing it before surgery is not as beneficial as determining movement and sensation. (Lewis 8 ed, pp. 339, 342 & 1631).

What is the priority assessment information to obtain from a client who is being admitted with a tentative diagnosis of fractured hip?

1. Circulation and sensation distal to the fracture
2. Amount of swelling around the fracture site
3. Degree of bone healing that has occurred
4. Amount of pain that the fracture and healing are causing

Answer: 1

Rationale: Circulation and neurosensory status distal to the fracture are always priorities for clients with fractures. The amount of swelling is important; however, the primary concern regarding swelling is circulatory and neurosensory deficits. The amount of bone healing cannot be assessed. There is concern regarding pain, but circulatory and neurologic checks are the priority actions. (Lewis 8 ed, p. 1596).

For a client with severe painful osteoarthritis, a regimen of heat, massage, and exercise will:

1. Help relax muscles and relieve pain and stiffness
2. Restore range of motion previously lost
3. Prevent the inflammatory process
4. Help the client cope with pain effectively

Answer: 1

Physical therapy relaxes muscles and relieves the aching and stiffness of the involved joints. It usually does not restore lost range of motion, and it does not prevent inflammation. Physical therapy does make the client more comfortable, but it does not assist in coping with pain. (Lewis 8 ed, p. 1644).

A client is being treated with Buck's traction. What are important nursing interventions for this client?

1. Remove the traction boot every 6 hours to provide skin care.
2. Check and clean the pin sites at least three times daily.
3. Check the area around the hip where the traction is applied.
4. Verify that weights are in the amounts ordered and are hanging freely.

Answer: 4

Always check the weight amounts and make sure they are not lodged against the bed or another area. There are no pin sites because Buck's traction is skin traction, not skeletal traction. The traction boot does not need to be removed as often as every 6 hours to provide skin care. (Lewis 8 ed, p. 1593).

A client has a long leg plaster cast applied. What nursing action should be implemented while the cast is still wet?

1. Use only the fingertips when moving the cast.
2. Keep the client and cast covered with blankets.
3. Support the cast on plastic-covered pillows.
4. Place a heat lamp directly over the cast.

Answer: 3

The cast should be supported on a pillow that will not absorb the moisture and will not keep the cast wet (e.g., plastic-covered pillow). Palms of the hand should be used in turning the client. Heat should not be applied to a damp cast. (Lewis 8 ed, p. 1593).

The postoperative nursing care plan for a client who has had a right leg amputation includes:

1. Applying ice packs to the residual limb for 72 hours
2. Having the client lie on his or her abdomen for 30 minutes 3 to 4 times/day
3. Wrapping the residual limb with elastic bandages from proximal to distal ends
4. Managing client's pain with anti-inflammatory medications

Answer: 2

Client should lie on the abdomen for 30 minutes 3 to 4 times/day and position the hip in extension while prone. Also, to prevent flexion contractures clients should avoid sitting in a chair for more than an hour. The residual limb is wrapped from distal to proximal. Ice packs are not used on the residual limb after surgery because the cold restricts blood flow. Anti-inflammatory medications may be used for pain relief but not to prevent edema. (Lewis 8 ed, p. 1612).

Which of the following would be appropriate client education before having a bone scan?

1. Maintain NPO status for 8 before the procedure.
2. The procedure will involve intravenous injection of radioisotopes.
3. The procedure will involve a small incision where bone tissue is removed for biopsy.
4. The client will have to lie very still during the scan.
5. Avoid stimulants such as caffeine for 24 hours before the procedure.
6. Increase intake of fluids after the procedure is completed

Answers: 2, 4, 6

The procedure will include an IV injection of radioisotopes, during the scan, the client will have to be very still or the scan pictures may not be clear, and increasing fluids afterwards will promote excretion of the radioisotopes. Food or fluids are not limited before the scan, and no biopsy of the bone will be taken. (Lewis 8 ed, p. 1579).

In taking the health history of a client with severe painful osteoarthritis, the nurse would expect the client to report which of the following?

1. A gradual onset of the disease, with involvement of weight-bearing joints
2. A sudden onset of the disease, with involvement of all joints
3. Complaints of joint stiffness after periods of activity
4. Pain that improves with use of the joint

Answer: 1

Osteoarthritis has a gradual onset and affects weight-bearing joints with pain that is more pronounced after exercise. The onset of osteoarthritis is gradual, not sudden. The client will usually complain of increased stiffness in the morning and also following periods of inactivity, with improvement following activity. Joint pain generally worsens with joint use and in the early stages of osteoarthritis, joint pain is relieved by rest. (Lewis 8 ed, p. 1642).

The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding(s) would cause the nurse concern regarding the development of compartmental syndrome?

1. Decrease in pulse rate in leg
2. Paresthesia distal to area of injury
3. Toes on affected leg cool to touch and edematous
4. Complaints that pins are hurting
5. Complaints of leg pain unrelieved by analgesics or repositioning
6. Client angry and calling loudly to the nurse every 10 minutes
Answers: 2, 3, 5

Paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. With a femur fracture, there is some degree of edema postoperatively that may leave the toes on the affected leg cool to touch. The decrease in pulse rate is not an indication of pressure, a decrease in pulse strength is. The pins usually do not cause undue pain, and frequently, the client is angry regarding the immobility and does not use effective coping measures. (Lewis 8 ed, p. 1603).

The nurse is planning discharge teaching for a client who has just been placed on biologic therapy with etanercept (Enbrel)? What will be important for the nurse to include in teaching this client regarding this medication?

1. Dizziness or headache may occur side effects.
2. A rubella vaccine is recommended within 2 months of beginning this medication.
3. There may be some pain, itching, or redness at the injection site.
4. Lab work every 6 months will be necessary to check your liver function.
5. Take an iron supplement daily as iron deficiency is a side effect of this medication.
6. A runny nose or cough may occur when taking this medication

Answers: 1, 3, 6

Possible side effects of etanercept (Enbrel) include dizziness, headache, pain, redness or itching at the injection site, and upper respiratory symptoms, including rhinitis and cough. Live virus vaccines (such as rubella) should not be taken during treatment with etanercept, and checking liver functions routinely or taking an iron supplement with this medication is not necessary.

Which medication is most often used in the initial treatment of the client with rheumatoid arthritis?

1. Corticosteroids
2. Aspirin
3. Disease-modifying antirheumatic drugs
4. Gold salts

Answer: 2

Acetylsalicylic acid (aspirin) is the drug of choice and is the most effective in the early treatment of rheumatoid arthritis (RA) because of its immediate effects on relieving symptoms associated with RA. Corticosteroids and gold salts typically are not used in the early or initial treatment. Disease-modifying antirheumatic drugs (DMARDs) are usually started within 3 months of diagnosis. However, DMARDs take several weeks to months to become effective in preventing further joint deterioration.

A client has been diagnosed with gouty arthritis and has begun taking allopurinol (Zyloprim). What is important for the nurse to discuss with the client regarding this medication?

1. The medication should be taken with food, and intake of liquids should be increased throughout the day.
2. Diarrhea and nausea may occur soon after therapy begins and will subside with no treatment.
3. The client should call the doctor if severe headaches occur after taking the medication.
4. The client should start to feel some pain relief within the first 24 hours after taking the medication.

Answer: 1

The client must take the medication with food to avoid gastrointestinal upset. The medication is being given because of the hyperuricemia; therefore the client needs to increase fluids to flush out the excess uric acid. It will take the medication several days to achieve maximum effectiveness; pain relief will not be immediate. Diarrhea, nausea, and headache are not common side effects.

A woman is beginning to take alendronate (Fosamax) for treatment of her osteoporosis. The nurse is discussing with the woman how she should take the medication. What is very important to include in this discussion?

1. The medication must be taken on an empty stomach, and no food must be eaten for at least 30 minutes after the medication is taken.
2. The medication should be taken with a minimal amount of water, and the client should lie down after taking it.
3. The client should take the medication every night at bedtime, and she should not stop taking it abruptly.
4. Orthostatic hypotension may be a potential side affect; she should stand up slowly and make sure she has her balance.

Answer: 1

For the medication to be adequately absorbed, there must be no food in the stomach. A large glass of water should be used to take the medication to make sure it does not lodge in the esophagus. The client should not lie down for 30 minutes after taking the medication because any gastric reflux of the medication can be very irritating to the esophagus. Orthostatic hypotension is not a side effect, and the medication should not be taken at bedtime.

A client is having difficulty with muscle spasms and is being treated with methocarbamol (Robaxin). What comment by the client would indicate to the nurse that the client did not understand the precautions regarding this medication?

1. "I understand I should not drive when I take this medication."
2. "I know I should not drink any alcohol while I am taking this medication."
3. "I will get up carefully in case I get dizzy."
4. "I will continue to take care of my 3-month-old grandson."

Answer: 4

Caring for a 3-month-old will require mental alertness and physically carrying the infant. The client cannot afford to be drowsy and fall asleep or to stumble and fall with the infant. The client should avoid driving and alcohol intake. There may be significant CNS depression, so the client should be careful when ambulating.

A client with a history of arthritis and gastric ulcers comes to the clinic complaining of severe gastrointestinal distress. Which would be the most important question for the nurse to ask the client?

1. "Are you taking the medications with food?"
2. "Are you taking the medications with water?"
3. "Have you changed your eating habits recently?"
4. "What medication are you using for the arthritis?"

Answer: 4

The most important information for the nurse to determine is what medications the client is taking for treatment of the arthritis. The medications should be evaluated and possibly changed.

A client has cyclobenzaprine (Flexeril) prescribed for muscle spasms. What would be important to teach this client regarding the medication?

1. Call the doctor if you get drowsy or dizzy.
2. Get up slowly and stand in place if you are dizzy.
3. It will be important to come back in 2 weeks to have drug levels drawn.
4. The tablets should be taken only with meals.

Answer: 2

Postural hypotension may be a problem initially. The client should not participate in any activity that requires mental alertness for safety. The dizziness and drowsiness are common occurrences and are not alarming. The nurse should teach the client how to manage orthostatic hypotension. Drug levels do not have to be monitored, and the client may take the medication at any time.

A client has been taking low-dose aspirin and prednisone (Deltasone) for the past several years for treatment of her rheumatoid arthritis. What finding would indicate a problem with the drug therapy?

1. Tarry stools
2. Decreased leukocyte count
3. Thrombocytopenia
4. Postural hypotension

Answer: 1

Development of tarry stools indicates gastrointestinal bleeding. Both the aspirin and the corticosteroids place the client at high risk for the development of a peptic ulcer and subsequent GI bleeding. Postural hypotension, thrombocytopenia, and decreased leukocytes are not directly associated with corticosteroids.

A client is taking allopurinol (Zyloprim) 200 mg by mouth every day. Which statement by the client indicates an understanding of the nurse's instruction?

1. "My diet will consist of more meat and fewer sugars."
2. "I need to drink at least ten 8-ounce glasses of water a day."
3. "I should increase my intake of dairy products."
4. "This medication should be taken on an empty stomach."

Answer: 2

Allopurinol (Zyloprim) reduces uric acid concentration in the serum and in the urine. It must be taken with at least 8 or more glasses of water to increase urine flow to reduce the risk of renal calculi formation. Increasing protein, limiting sugar, and increasing dairy products do not affect the action of Zyloprim. The medication may cause gastric irritation, and it may be taken with food to decrease incidence of gastric irritation.

A client with a below-the-knee amputation is complaining of phantom limb pain that is not responsive to administration of narcotic analgesics. The client is started on gabapentin (Neurontin). The nurse explains to the client that this medication works by:

Peptic ulcer: A peptic ulcer is a defect in the lining of the stomach or the first part of the small intestine, an area called the duodenum. A peptic ulcer in the stomach is called a gastric ulcer. An ulcer in the duodenum is called a duodenal ulcer.

A client with a below-the-knee amputation is complaining of phantom limb pain that is not responsive to administration of narcotic analgesics. The client is started on gabapentin (Neurontin). The nurse explains to the client that this medication works by:

1. Binding at receptor pain sites to decreases neuropathic pain.
2. Decreasing inflammation and irritation at the site of the nerve ending
3. Decreasing pain by inhibiting the pain impulse at the level of the axion
4. Affecting the central nervous system and altering processes affecting pain perception
Answer: 1

Neurontin is used to treat neuropathic pain, which is often the basis for phantom limb pain in amputees. Drugs to decrease inflammation are corticosteroids. Narcotics affect the CNS and the perception of pain.

A client with rheumatoid arthritis has a history of long-term nonsteroidal antiinflammatory drug (NSAID) use and has developed peptic ulcer disease. Which medication would the nurse anticipate administering?

1. Omeprazole (Prilosec)
2. Ticlopidine (Ticlid)
3. Cyanocobalamin (vitamin b12)
4. Prednisolone (prelone)

Answer: 1

Omeprazole (Prilosec) is a proton-pump inhibitor, which suppresses gastric acid secretion. Cyanocobalamin is used to treat vitamin B12 deficiency. Ticlopidine is an antiplatelet agent used to reduce the risk of stroke. Prednisolone is a glucocorticoid used to treat several inflammatory disorders and contributes to gastric ulcer development. (Lehne, 7 ed., p. 917.)

Heparin is administered prophylactically to prevent thromboembolic complications in clients who are immobilized for prolonged periods. It is not effective in preventing fat emboli or venous stasis or promoting vascular perfusion.

A client begins receiving methotrexate (Rheumatrex) for severe symptoms of rheumatoid arthritis. What is the most important information for the nurse to give this client regarding the medication?
1. Take extra fiber and fluids to counteract the constipating effect.
2. It is very important to have periodic lab work done.
3. Take the drug on an empty stomach.
4. Hirsutism and menstrual changes sometimes develop as side effects.

Answer: 2

Lab work will need to be done periodically during administration to monitor for the development of anemia, leukopenia, thrombocytopenia, and/or hepatic toxicity. Hirsutism and menstrual changes occur with long-term corticosteroid use. Methotrexate should be given 1 hour before or 2 hours after meals to prevent vomiting when given PO. Antiemetics are given concurrently with the medication.

A client is confined to bed with a fracture of the left femur. He begins receiving subcutaneous heparin injections. What is the purpose of this medication?

1. To prevent thrombophlebitis and pulmonary emboli associated with immobility

2.To promote vascular perfusion by preventing formation of microemboli in the left leg

3.To prevent venous stasis, which promotes vascular complications associated with immobility

4.To decrease the incidence of fat emboli associated with long bone fractures

Answer: 1

A client is scheduled for a routine glycosylated hemoglobin (HbA1C) test. What is important for the nurse to tell the client before this test?

1. Drink only water after midnight and come to the clinic early in the morning.
2. Eat a normal breakfast and be at the clinic 2 hours later.
3. Expect to be at the clinic for several hours because of the multiple blood draws.
4. Come to the clinic at the earliest convenience to have blood drawn.

Rationale: (4)
Glucose attaches to the hemoglobin molecule of the red blood cell. A glycosylated hemoglobin test gives an average of blood glucose over the past 3 to 4 months, and a blood sample can be obtained at any time during the day. It is not used in the diagnosis of diabetes and does not need to be a fasting specimen. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1223.)

What will the nurse teach the client with diabetes regarding exercise in the treatment program?

1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin.
2. With an increase in activity, the body will use more carbohydrates; therefore, more insulin will be required.
3. Exercise increases the HDL and decreases the chance of stroke and heart disease.
4. The increase in activity results in an increase in the use of insulin; therefore, the client should decrease his or her carbohydrate intake.
5. Exercise will improve pancreatic circulation and stimulate the islets of Langerhans to increase the production of intrinsic insulin.

Rationale:(1, 3)
As carboyhdrates are used for energy, insulin needs decrease. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to reach target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation. Increased HDLs have been associated with a decrease in syndrome x (Metabolic Syndrome). (Lewis, Dirksen, Heitkemper, et al, 8 ed., pp. 959, 1219, 1223.)

A nurse knows the clinical manifestations of a client with Addison's disease include which of the following?

1. Nausea
2. Hypothermia
3. Hypertension
4. Hyperpigmentation
5. Hypotension
6. Hypernatremia

Rationale: (1, 4, 5)
Addison's disease is due to a hypofunctioning of the adrenal cortex. The clinical manifestations have a very slow onset, and skin hyperpigmentation (melanosis) is a classic sign. This bronze coloring of the skin is seen primarily in those areas exposed to the sun, pressure points, joints, and in skin creases (especially on the palms, knuckles, and elbows). Fatigue, nausea, weight loss, hypotension, hyponatremia, and hyperkalemia are other findings associated with the condition. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1280.)

A client is receiving NPH insulin 20 units subcutaneously at 0700 hours daily. At 1500 hours, the nurse finds the client apparently asleep. How would the nurse know whether the client was having a hypoglycemic reaction?

1. Feel the client and bed for dampness.
2. Observe the client for Kussmaul respirations.
3. Smell the client's breath for acetone odor.
4. Note if the client is incontinent of urine.

Rationale: (1)
When clients are sleeping, the only observable symptom of hypoglycemia is diaphoresis. Kussmaul breathing and acetone odor to breath are indicative of hyperglycemia. Incontinence is not associated with hypoglycemia and polyuria may be associated with hyperglycemia. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 1245.)

What is important to teach a client with adrenal insufficiency who has a prescription for prednisone?

1. Be sure to include foods that are low in potassium in the diet.
2. Slowly change positions to avoid dizziness and fainting.
3. Watch for signs of low blood sugar: headache, shakiness, and diaphoresis.
4. Signs of fluid retention may occur while taking this drug.

Rationale (4)
Report any excessive weight gain or swelling to the health care provider, because they may indicate an adverse effect of the medication. The client taking prednisone needs to consume a high potassium diet, as prednisone causes hypokalemia. Hypertension, not orthostatic hypotension, is a side effect of taking glucocortocoids. Hyperglycemia can occur with prednisone use, not hypoglycemia. (Lehne, 7 ed., pp. 854-855.)

The nurse is discussing with a child and family the various sites used for insulin injections. The nurse would explain that the following site has the fastest rate of absorption:

1. Abdomen
2. Thigh
3. Buttock
4. Arm

Rationale: (1)
The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration. (Hockenberry, Wilson, 9 ed., p. 1610.)

A client with an acute exacerbation of ulcerative colitis has type 2 diabetes that is controlled with diet and metformin (Glucophage). The health care provider orders prednisone to reduce inflammation in the colon. What would the nurse anticipate as part of the client's plan of care?

1. Increase in fiber and calories in daily diet
2. Increase in adverse side effects caused by the combination drug therapy
3. Add insulin therapy while on prednisone
4. More frequent monitoring of glycosolated hemoglobin levels

Rationale: (3)
The addition of insulin to the client's diabetic medication regime would be required because of prednisone, which in high doses increases the blood sugar. More frequent monitoring of glycosolated hemoglobin is unnecessary, but rather more frequent glucose monitoring while on the insulin. Taking the two medications together should not increase the likelihood of adverse effects. Prednisone will increase the appetite, so calories and fluids should be monitored to avoid weight gain and fluid retention. (Lewis, et al, 8 ed., p. 1222.)

A client is learning to inject his own insulin. Which of the following nursing observations would indicate to the nurse that the client needs further teaching?

1. Wipes the top of the insulin vial with alcohol
2. Withdraws the prescribed amount of insulin within 0.2 mL
3. Refers to the abdominal injection chart and chooses a previously unused site
4. Keeps the insulin in the refrigerator and prepares and injects it immediately

Rationale: (4)
Cold insulin increases the risk of lipodystrophy. All extra unopened bottles may be stored in the refrigerator, but the bottle currently being used should remain at room temperature, and the insulin should be injected at room temperature. Insulin should not be subjected to extreme temperatures, but it is stable at room temperature. (Lehne, 7 ed., p. 670; Lewis, et al, 8 ed., pp. 1226, 1227.)

A child with newly diagnosed diabetes is in the emergency room and is unconscious. Glucagon has been prescribed for treatment of hypoglycemia. What would be important nursing management?

1. Watch for side effects of hypoglycemia
2. Child usually awakens within 20 minutes of receiving glucagon.
3. Vomiting may occur after administration, so aspiration precautions should be taken.
4. Do not rotate sites for administration, because even absorption in the abdomen is best.
5. Give PO glucagon once the client has consciousness.
6. Monitor blood values for increasing blood sugar.

Rationale: (1, 2, 3, 6)
Glucagon is the medication of choice used to elevate blood sugar levels after insulin overdose. It does not correct hypoglycemia resulting from starvation. Rebound hypoglycemia is a potential adverse effect, which is why it is important for the client to have carbohydrates once consciousness returns. No significant side effects exist. If unconscious when administered, the child usually awakens in 5 to 20 minutes after receiving glucagon. Vomiting may occur after administration, so aspiration precautions should be taken by placing the child on the side. Blood work to monitor an increase in blood sugar (desired outcome) would be collected. IV is the preferred method of glucagon administration, although the medication is able to be given subQ and IM, not PO. When client is conscious, oral carbohydrates and protein should be given. (Lehne, 7 ed., p. 683.)

A client with type 1 diabetes calls the nurse because of nausea and not feeling well. What would be important for the nurse to tell the client?

1. "Hold the oral hypoglycemics until he can begin eating again."
2. "Take the insulin as scheduled, increase water intake, and continue to monitor the blood glucose."
3. "Take his regular dose of insulin, replace food with fruit juices, and monitor his blood glucose."
4. "Do not take any insulin as long as he is nauseous and cannot maintain intake."

Rationale: (3)
This client is on insulin for his diabetic control. He should continue taking the regularly scheduled dose of insulin and eating the prescribed diet, as well as increasing the amount of low-calorie fluids (e.g., broth, water, decaffeinated tea). If the client is unable to consume solid foods or keep food down, then he can increase his caloric intake by drinking carbohydrate fluids (e.g., juices and soups). It is important for the client to check his blood glucose levels every 4 hours. Additionally, for the type 1 diabetic client with blood glucose levels greater than 240 mg/dL, urine testing for ketones every 3 to 4 hours is required, and findings should be reported to the healthcare provider. The blood sugar may continue to rise because of the illness, which is why it is important to continue medication. (Lewis, et al, 8 ed., p. 1236-1238.)

The physician orders hydrocortisone daily for a client with Addison disease. The nurse explains to the client that the dosage may need to be adjusted because of which concern?

1. Increased food intake
2. An increase in blood glucose levels
3. Increased stress levels
4. Stomach discomfort

Rationale: (3)
Stress levels in the body will cause utilization of increased amounts of cortisol. With the lack of steroids caused by adrenal insufficiency associated with Addison disease, it would be important to maintain the level of cortisone in the body to keep the body functioning appropriately. (Lewis, et al, 8 ed., p. 1281.)

An 8-year-old boy with type 1 diabetes has been receiving NPH and regular insulin. His mother calls the nurse and explains that the child's morning blood glucose readings have been above 200 mg/dL. What should the nurse advise the mother to do?

1. Raise his NPH dose by two units to cover the elevation in the early morning.
2. Change the time of the night dose to 1 hour before sleep.
3. Do blood glucose checks during the night.
4. Keep a glass of water near the bed to dilute the sugar levels during the night.

Rationale: (3)
The child is having a rapid decrease in his blood glucose level during the night, causing a hyperglycemic rebound response. The rebound rise in the blood sugar reading is picked up in the morning blood glucose reading, which can lead to misinterpretation. This may be classified as a Somogyi effect. (Hockenberry, Wilson, 9 ed., p. 1603.)

The nurse is teaching the parents of a child who is experiencing difficulty with control of his diabetes. Which of the following agents should the nurse teach the parents to administer if their child loses consciousness and has a severe hypoglycemic reaction?

1. IV dextrose
2. Subcutaneous insulin
3. Subcutaneous glucagon
4. Oral fast-acting carbohydrate

Rationale: (3)
If the child has a severe hypoglycemic episode, he frequently is neurologically compromised. It is important to administer subcutaneous or intramuscular glucagon. Subcutaneous insulin would further worsen the child's condition. IV dextrose would be given in the hospital. Oral administration of fast-acting carbohydrates is reserved for the conscious child who is not having a severe hypoglycemic reaction. (Lehne, 7 ed., p. 672.)

If dietary trays are usually brought to the nursing unit at 8:00 am, the nurse should plan to administer intermediate-acting insulin (Humulin N), 40 units, subcutaneously to a client between:

1. 5:00 and 5:30 am
2. 6:30 and 7:00 am
3. 9:30 and 10:30 am
4. 11:00 and 11:30 am

Rationale: (2)
Intermediate-acting insulin, such as Humulin N, should be given 60 to 90 minutes before a meal. Therefore, if the breakfast tray arrived at 8:00 am, a client would need to receive the insulin between 6:30 and 7:30 am. Regular insulin usually is administered 30 minutes before a meal, and insulin lispro is given immediately (15 minutes) before or after meals. (Lehne, 7 ed., pp. 666-667.)

A client who is planning a trip to the beach is taking glipizide (Glucotrol). What would be important for the nurse to discuss with the client?

1. The importance of eating night-time and between-meal snacks
2. The problems associated with fluid retention in a warm climate
3. Skin sensitivity resulting from exposure to saltwater
4. Wearing sunscreen and avoiding direct sunlight

Rationale: (4)
Orally hypoglycemic agents, such as the sulfonylureas, may increase sensitivity to sunlight, resulting in sunburn (photosensitivity). The nurse must teach the client to wear sunscreen and to avoid excessive exposure to sunlight. Fluid retention is a prominent side effect of the "glitazones," or oral hypoglycemic medications, such as rosiglitazone (Avandia). (Lehne, 7 ed., p. 1026.)