Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client is experiencing DKA?
A. Rapid pulse
Choice A: Rapid pulse. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause rapid pulse due to increased sympathetic nervous system activity and decreased cardiac output.
B. Clammy skin
Choice B: Clammy skin. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia. Hypoglycemia can cause clammy skin due to increased sweating and vasoconstriction.
C. Confusion
Choice C: Confusion is commonly found in HHS rather than DKA.
D. Polydipsia
Choice D: Polydipsia. This is a finding that indicates that the client is experiencing DKA due to the high level of glucose in the blood. Hyperglycemia in DKA can cause polydipsia, which is excessive thirst, due to osmotic diuresis and dehydration.
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Full Explanation
Choice A: Rapid pulse. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause rapid pulse due to increased sympathetic nervous system activity and decreased cardiac output.
Choice B: Clammy skin. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia. Hypoglycemia can cause clammy skin due to increased sweating and vasoconstriction.
Choice C: Choice C: Confusion is commonly found in HHS rather than DKA.
Choice D: Polydipsia. This is a finding that indicates that the client is experiencing DKA due to the high level of glucose in the blood. Hyperglycemia in DKA can cause polydipsia, which is excessive thirst, due to osmotic diuresis and dehydration.
Similar Questions
A nurse is caring for a client who has hyperparathyroidism. Based on this diagnosis, the nurse should monitor the client for which of the following complications?
A. Dysphagia
Choice A: Dysphagia. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Dysphagia is difficulty swallowing, which can be caused by disorders of the esophagus, throat, or nervous system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
B. Pathologic fractures
Choice B: Pathologic fractures. This is a complication that the nurse should monitor the client for who has hyperparathyroidism, which is a condition that occurs when the parathyroid glands produce too much parathyroid hormone (PTH). PTH regulates calcium and phosphorus levels in the blood and bones. Hyperparathyroidism can cause hypercalcemia, which is a high level of calcium in the blood, and hypophosphatemia, which is a low level of phosphorus in the blood. These imbalances can lead to bone resorption, which is the breakdown of bone tissue and release of calcium into the blood. Bone resorption can weaken the bones and increase the risk of pathologic fractures, which are fractures that occur due to disease or injury to the bone.
C. Fluid retention
Choice C: Fluid retention. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Fluid retention is excess fluid accumulation in the body, which can be caused by disorders of the heart, kidney, liver, or lymphatic system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
D. Impaired skin integrity
Choice D: Impaired skin integrity. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Impaired skin integrity is damage or loss of skin tissue, which can be caused by trauma, infection, inflammation, or pressure. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Full Explanation
Choice A: Dysphagia. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Dysphagia is difficulty swallowing, which can be caused by disorders of the esophagus, throat, or nervous system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Choice B: Pathologic fractures. This is a complication that the nurse should monitor the client for who has hyperparathyroidism, which is a condition that occurs when the parathyroid glands produce too much parathyroid hormone (PTH). PTH regulates calcium and phosphorus levels in the blood and bones. Hyperparathyroidism can cause hypercalcemia, which is a high level of calcium in the blood, and hypophosphatemia, which is a low level of phosphorus in the blood. These imbalances can lead to bone resorption, which is the breakdown of bone tissue and release of calcium into the blood. Bone resorption can weaken the bones and increase the risk of pathologic fractures, which are fractures that occur due to disease or injury to the bone.
Choice C: Fluid retention. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Fluid retention is excess fluid accumulation in the body, which can be caused by disorders of the heart, kidney, liver, or lymphatic system. It is not related to hyperparathyroidism or calcium and phosphorus levels.
Choice D: Impaired skin integrity. This is not a complication that the nurse should monitor the client for who has hyperparathyroidism. Impaired skin integrity is damage or loss of skin tissue, which can be caused by trauma, infection, inflammation, or pressure. It is not related to hyperparathyroidism or calcium and phosphorus levels.
A nurse is caring for a client who is postoperative and has a history of Addison’s disease. For which of the following manifestations should the nurse monitor?
A. Hypernatremia
Choice A: Hypernatremia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypernatremia is a high level of sodium in the blood, which can be caused by dehydration, excessive sodium intake, or kidney dysfunction. It is not related to Addison’s disease or cortisol and aldosterone levels.
B. Bradycardia
Choice B: Bradycardia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Bradycardia is a slow heart rate, which can be caused by vagal stimulation, medication side effects, or cardiac disorders. It is not related to Addison’s disease or cortisol and aldosterone levels.
C. Hypotension
Choice C: Hypotension. This is a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease, which is a condition that occurs when the adrenal glands do not produce enough cortisol and aldosterone. Cortisol is a hormone that regulates the metabolism of carbohydrates, proteins, and fats, and helps the body cope with stress. Aldosterone is a hormone that regulates the balance of sodium and potassium in the blood and fluid volume. Addison’s disease can cause hypotension, which is a low blood pressure, due to decreased aldosterone production and fluid loss.
D. Hypokalemia
Choice D: Hypokalemia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypokalemia is a low level of potassium in the blood, which can be caused by diuretics, vomiting, diarrhea, or alkalosis. It is not related to Addison’s disease or cortisol and aldosterone levels.
Full Explanation
Choice A: Hypernatremia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypernatremia is a high level of sodium in the blood, which can be caused by dehydration, excessive sodium intake, or kidney dysfunction. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice B: Bradycardia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Bradycardia is a slow heart rate, which can be caused by vagal stimulation, medication side effects, or cardiac disorders. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice C: Hypotension. This is a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease, which is a condition that occurs when the adrenal glands do not produce enough cortisol and aldosterone. Cortisol is a hormone that regulates the metabolism of carbohydrates, proteins, and fats, and helps the body cope with stress. Aldosterone is a hormone that regulates the balance of sodium and potassium in the blood and fluid volume. Addison’s disease can cause hypotension, which is a low blood pressure, due to decreased aldosterone production and fluid loss.
Choice D: Hypokalemia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypokalemia is a low level of potassium in the blood, which can be caused by diuretics, vomiting, diarrhea, or alkalosis. It is not related to Addison’s disease or cortisol and aldosterone levels.
A nurse is reinforcing teaching of a female client who has a family history of type 2 diabetes mellitus. The nurse should include which of the following risk factors for developing type 2 diabetes mellitus in the teaching?
A. Sedentary lifestyle
Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.
B. Triglyceride level of 100 mg/dL
Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.
C. Blood glucose of 98 mg/dL
Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.
D. Recent viral infection
Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that atacks the beta cells and causes type 1 diabetes mellitus.
Full Explanation
Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.
Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.
Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.
Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that attacks the beta cells and causes type 1 diabetes mellitus.