Question

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused. flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

Answer 1

Correct Answers:

Regular insulin

Rationale :

🔷 Regular insulin is the insulin used for diabetic ketoacidosis because it can be given IV and has a rapid onset.

🔷 DKA is an emergency caused by severe insulin deficiency, hyperglycemia, dehydration, ketosis, and metabolic acidosis.

🔷 IV regular insulin lowers serum glucose and stops ketone production by moving glucose into cells and reducing fat breakdown.

🔷 The nurse should monitor blood glucose, potassium, anion gap, hydration status, and neurologic response during therapy.

🔷 Potassium must be monitored closely because insulin shifts potassium into cells and can cause dangerous hypokalemia.

Insulin glargine

🔷Insulin glargine is a long-acting basal insulin and is not used for rapid correction of DKA.

🔷 It cannot be used IV for emergency glucose reduction.

NPH insulin

🔷NPH is an intermediate-acting insulin used for longer glucose control.

🔷It does not act fast enough for acute DKA treatment.

Insulin detemir

🔷Insulin detemir is a long-acting basal insulin.

🔷It is not appropriate for immediate IV management of DKA.

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Answer 2

Correct Answers:

0.9% sodium chloride IV bolus

Rationale :

🟩 The priority prescription in DKA with a glucose of 925 mg/dL is 0.9% sodium chloride IV bolus to restore circulating volume.

🟩 DKA causes severe dehydration because hyperglycemia produces osmotic diuresis, leading to fluid and electrolyte loss.

🟩 Isotonic saline expands the intravascular space, improves tissue perfusion, and supports kidney clearance of glucose and ketones.

🟩 Fluid resuscitation is started before or with insulin therapy because dehydration contributes to hypotension, tachycardia, and poor perfusion.

🟩 Once glucose decreases to about 200 to 250 mg/dL, dextrose-containing fluids may be added to prevent hypoglycemia while insulin continues clearing ketones.

Dextrose 5% in 0.45% sodium chloride

🟩Dextrose-containing fluids are not the initial treatment when blood glucose is extremely high.

🟩They are added later when glucose falls and insulin must continue to correct acidosis.

Oral hypoglycemic medications

🟩Oral medications are not appropriate for acute DKA because the client needs rapid IV therapy and close monitoring.

🟩DKA requires fluids, IV regular insulin, and electrolyte replacement.

Glucocorticoid medications

🟩Glucocorticoids can increase blood glucose and worsen hyperglycemia.

🟩 They do not treat DKA and may aggravate the metabolic problem.

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Answer 3

Correct Answers:

"l will need to wipe my perineal area from back to front after urination."

Rationale :

🟨 This statement indicates a need for further teaching because perineal care should be done front to back.

🟨 Wiping from back to front can move fecal bacteria, especially E. coli, from the anal area toward the urethra.

🟨 This increases the risk for urinary tract infection, particularly in females because the urethra is short and close to the anus.

🟨 Proper hygiene helps reduce bacterial entry into the urinary tract and supports UTI prevention.

🟨 The nurse should correct the client by teaching front-to-back wiping after urination and bowel movements.

“I will need to drink apple cider vinegar each day.”

🟨Apple cider vinegar is not an evidence-based UTI prevention measure and should not replace proven strategies.

🟨However, the most clearly unsafe hygiene statement is wiping from back to front.

“I need to drink 8 cups of liquid each day.”

🟨Adequate fluids help dilute urine and promote regular flushing of bacteria from the urinary tract.

🟨This is appropriate teaching unless the client has a fluid restriction.

“I will need to empty my bladder regularly and completely.”

🟨Regular and complete bladder emptying helps prevent urinary stasis.

🟨Urinary stasis allows bacteria to multiply and increases UTI risk.

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Answer 4

Correct Answers

Monitor vital signs daily. [ contraindicated ]
Encourage the client to attend group activities. [ contraindicated ]
Reduce the level of stimuli in the client's environment. [ anticipated ]
Weigh the client daily. [ anticipated ]
Provide the client with a high-calorie, high protein shake every hour. [ anticipated ]
Provide frequent rest periods . [ anticipated ]

Rationale :

Monitor vital signs daily- Contraindicated

🔷 Daily vital signs are not frequent enough because the client is acutely manic, agitated, pacing, and has persistent tachycardia, tachypnea, and hypertension.

🔷 The client’s heart rate is 110 to 115/min, respiratory rate is 24/min, and blood pressure remains elevated around 166/90 mm Hg.

🔷 Acute mania can cause dehydration, exhaustion, poor intake, sleep deprivation, and physiologic instability.

🔷 More frequent monitoring is needed to detect worsening agitation, cardiovascular strain, dehydration, or medication effects.

🔷 This order is contraindicated because it underestimates the level of monitoring required for the client’s current condition.

Encourage the client to attend group activities-Contraindicated

🟩 Group activities are contraindicated during acute mania because they can increase environmental stimulation and worsen agitation.

🟩 The client is already pacing, refusing to sit, becoming agitated with questions, and is only oriented x2.

🟩 A highly stimulating group setting may increase impulsivity, conflict, distractibility, and unsafe behavior.

🟩 The priority is to provide a calm, structured environment with brief, simple interactions.

🟩 Group therapy can be introduced later when mood, behavior, sleep, and impulse control are more stable.

Reduce the level of stimuli in the client’s environment-Anticipated

🟨 Reducing environmental stimuli is anticipated because clients in acute mania are highly sensitive to stimulation.

🟨 Noise, crowds, bright lights, repeated questioning, and excessive activity can worsen agitation and hyperactivity.

🟨 A quiet, low-stimulation environment helps decrease escalation and promotes emotional regulation.

🟨 The nurse should use short, calm statements and provide clear limits in a nonthreatening manner.

🟨 This intervention supports safety and helps reduce the client’s risk for exhaustion or aggressive behavior.

Weigh the client daily-Anticipated

🟧 Daily weights are anticipated because the client has not eaten, slept, or taken medications for at least 2 days.

🟧 Acute mania increases energy expenditure due to pacing, restlessness, decreased sleep, and poor nutritional intake.

🟧 The client also has type 2 diabetes mellitus, so nutrition and hydration status require close monitoring.

🟧 Daily weights help assess fluid balance, nutritional decline, and response to interventions.

🟧 Weight trends are especially important when the client is too agitated to provide a reliable intake history.

Provide the client with a high-calorie, high-protein shake every hour-Anticipated

🟥 High-calorie, high-protein drinks are anticipated because manic clients often cannot sit long enough to eat full meals.

🟥 The client has not eaten for at least 2 days and is pacing continuously, increasing calorie use.

🟥 Portable nutrient-dense foods and drinks help maintain energy, glucose stability, and hydration.

🟥 This is especially important because the client has type 2 diabetes mellitus, making missed meals and irregular intake clinically concerning.

🟥 Frequent small nutritional offerings are safer and more realistic than expecting the client to sit for full meals.

Provide frequent rest periods-Anticipated

🟪 Frequent rest periods are anticipated because the client has not slept for at least 2 days.

🟪 Sleep deprivation worsens mania, irritability, impaired judgment, and physiologic stress.

🟪 Rest periods help reduce stimulation and prevent exhaustion from constant pacing and hyperactivity.

🟪 The nurse should provide a quiet environment and encourage short, structured rest opportunities.

🟪 Rest supports stabilization and helps reduce escalation of manic behavior.

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Answer 5

Correct Answers:

Time constraints
Restricting foods high in potassium, sodium, and phosphorus
Restricting fluid intake

Rationale :

Time constraints

🔷 Hemodialysis creates major time constraints because treatments are usually scheduled several times each week.

🔷 Each session can take several hours, and the client must also account for travel time, preparation, and recovery after treatment.

🔷 This can affect employment, school, family responsibilities, rest, and social activities.

🔷 The client may need to adjust daily routines around dialysis appointments and transportation needs.

🔷 Discussing time demands helps the client plan realistically and reduces frustration with lifestyle changes.

Restricting foods high in potassium, sodium, and phosphorus

🔷 Clients with end-stage kidney disease must often restrict potassium, sodium, and phosphorus because the kidneys cannot remove excess electrolytes effectively.

🔷 High potassium can cause dangerous cardiac dysrhythmias, including life-threatening rhythm changes.

🔷 High sodium increases thirst, fluid retention, hypertension, and edema.

🔷 High phosphorus contributes to bone disease, itching, and calcium-phosphorus imbalance.

🔷 Dietary restrictions can affect food choices, cultural meals, appetite, and social eating, making them important quality-of-life concerns.

Restricting fluid intake

🔷 Fluid restriction is often required because clients with end-stage kidney disease have limited ability to excrete extra fluid.

🔷 Excess fluid can cause hypertension, edema, shortness of breath, pulmonary edema, and heart strain.

🔷 Dialysis removes fluid, but too much fluid gain between treatments can make sessions harder to tolerate.

🔷 Clients may need to limit beverages, ice chips, soups, and foods that melt at room temperature.

🔷 Fluid restriction can be difficult because it affects thirst control, comfort, meal habits, and social routines.

Driving restrictions

🔷Driving is not routinely restricted simply because a client begins hemodialysis.

🔷Some clients may need transportation support if they feel weak after treatment, but this is not a standard dialysis restriction.

Limiting social activities to twice a week

🔷There is no standard rule limiting social activities to twice weekly for hemodialysis clients.

🔷Social activities can continue when planned around treatment schedules, energy level, infection prevention, and fluid or diet restrictions.

Restricting airplane travel

🔷Air travel is not routinely prohibited for clients receiving hemodialysis.

🔷Travel requires planning dialysis appointments at the destination, but it is not a standard restriction.

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Answer 6

Correct Answers:

Administer antibiotics.

Rationale :

🟩 Acute glomerulonephritis can occur after a streptococcal infection, so antibiotics may be prescribed to treat or eradicate the infection.

🟩 Antibiotic therapy helps prevent ongoing immune stimulation from the infectious trigger.

🟩 The condition involves inflammation of the glomeruli, which can cause hematuria, proteinuria, edema, hypertension, and reduced urine output.

🟩 Nursing care also includes monitoring blood pressure, intake and output, daily weight, edema, and renal laboratory values.

🟩 Treating the underlying infection supports recovery and helps reduce further renal injury.

Obtain weight weekly.

🟩Weight should be monitored daily, not weekly, because fluid retention can change rapidly.

🟩Daily weight is one of the best indicators of fluid balance in kidney disease.

Encourage increased fluid intake.

🟩Increased fluid intake is not appropriate when renal function is impaired and fluid retention may occur.

🟩Fluids may need to be restricted depending on urine output, edema, and blood pressure.

Encourage frequent ambulation.

🟩Frequent ambulation is not the priority intervention for acute glomerulonephritis.

🟩Rest may be needed during the acute phase, especially with hypertension, edema, or fatigue.

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Answer 7

Correct Highlights :

Substance use
Comorbidities in childhood
Treatment of animals
School history

Rationale :

Substance use

🟩The client was arrested for driving under the influence of alcohol, which indicates substance-related risk behavior.

🟩Substance use is commonly associated with conduct disorder and later antisocial personality disorder because it reflects impaired judgment, impulsivity, and disregard for safety.

🟩Driving under the influence places the client and others at risk for serious injury or death.

🟩Resisting arrest also supports a pattern of disregard for rules, authority, and legal consequences.

🟩This finding fits the client’s long history of behavioral dysregulation and legal problems.

Comorbidities in childhood

🟩 The client was diagnosed with ADHD at age 6 and conduct disorder at age 9, which are important childhood risk factors.

🟩 Conduct disorder before age 15 is a key developmental precursor for antisocial personality disorder in adulthood.

🟩 ADHD can contribute to impulsivity, poor frustration tolerance, and difficulty following rules when not well managed.

🟩 Early conduct disorder is strongly associated with aggression, property destruction, deceitfulness, theft, and serious rule violations.

🟩 This childhood pattern supports the progression toward adult antisocial behaviors.

Treatment of animals

🟩The client has a history of animal cruelty, which is a major warning sign of conduct disorder.

🟩Cruelty to animals reflects aggression, lack of empathy, and violation of the rights or safety of others.

🟩This behavior is clinically significant because conduct disorder includes aggression toward people or animals.

🟩Animal cruelty during childhood or adolescence is linked to more severe behavioral pathology.

🟩This finding supports concern for progression toward antisocial personality disorder.

School history

🟩The client was expelled from high school for possession of a weapon on school grounds, which reflects serious rule violation.

🟩School-related violence or weapon possession is consistent with conduct disorder because it shows disregard for safety and authority.

🟩The client also has a history of bullying, aggression, theft, vandalism, arson, and running away, which supports a long-standing conduct pattern.

🟩Conduct disorder involves repeated violation of social norms and the rights of others before adulthood.

🟩This school history is clinically important because it shows severe behavioral problems before age 18.

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Answer 8

Correct Answers:

Notify the provider of potential medication interactions.
Withhold next dose of lithium.
Educate the client about the need for hemodialysis.

Rationale :

Notify the provider of potential medication interactions

🟨The client has lithium toxicity with a lithium level of 2.2 mEq/L, which is above the toxic level of greater than 2 mEq/L.

🟨Furosemide can increase lithium levels by causing sodium and fluid loss, which makes the kidneys reabsorb more lithium.

🟨Ibuprofen, an NSAID, can also increase lithium levels by reducing renal blood flow and decreasing lithium clearance.

🟨The client’s vomiting, diarrhea, hyponatremia, drowsiness, slurred speech, and muscle twitching all support clinically significant lithium toxicity.

🟨The provider must be notified so interacting medications can be stopped or changed and toxicity treatment can begin promptly.

Withhold next dose of lithium

🟨The next dose of lithium should be withheld because the client’s lithium level is 2.2 mEq/L, which indicates toxicity.

🟨Continuing lithium would worsen neurologic symptoms such as slurred speech, drowsiness, muscle twitching, confusion, seizures, or coma.

🟨Vomiting and diarrhea increase dehydration risk, which further reduces lithium clearance and increases serum levels.

🟨The client also has sodium of 131 mEq/L, and low sodium increases lithium reabsorption in the kidneys.

🟨Holding lithium prevents further accumulation while the provider evaluates treatment needs and repeat lithium levels.

Educate the client about the need for hemodialysis

🟨 Hemodialysis may be needed because the lithium level is 2.2 mEq/L and the client has significant neurologic and gastrointestinal symptoms.

🟨 Lithium is cleared by the kidneys, and severe toxicity can require dialysis to rapidly remove lithium from the bloodstream.

🟨 The client has drowsiness, slurred speech, vomiting, diarrhea, muscle twitching, and hypotension, which show systemic toxicity.

🟨 Hemodialysis is especially considered when lithium toxicity is severe, symptomatic, or associated with declining clinical status.

🟨 Teaching prepares the client for urgent treatment aimed at preventing seizures, coma, dysrhythmias, and permanent neurologic injury.

Set up a dietary consult for a low-sodium diet.

🟨A low-sodium diet is unsafe for a client taking lithium because sodium depletion increases lithium reabsorption and raises lithium levels.

🟨The client should maintain consistent sodium and fluid intake unless otherwise directed.

Discuss contraception with the client.

🟨Contraception teaching can be relevant for clients taking lithium because lithium can pose pregnancy risks.

🟨However, this is not the priority during acute lithium toxicity with neurologic and gastrointestinal symptoms.

Administer prochlorperazine.

🟨Prochlorperazine may treat nausea, but it can worsen central nervous system depression and complicate assessment in a toxic client.

🟨The priority is to hold lithium, notify the provider, and manage toxicity rather than mask symptoms.

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Answer 9

Correct Answers:

Semi-Fowler's with neck in a neutral position

Rationale :

🔷 After a subtotal thyroidectomy, the client should be kept in Semi-Fowler’s position to reduce swelling and promote venous drainage from the operative site.

🔷 Keeping the neck in a neutral position prevents tension on the suture line and decreases the risk of bleeding.

🔷 This position also supports airway patency, which is a major priority after thyroid surgery.

🔷 The nurse should avoid neck flexion or hyperextension because either can place stress on the incision.

🔷 The head and neck should be supported with pillows when repositioning to prevent strain.

High Fowler’s with neck extended

🔷Neck extension can place tension on the thyroidectomy incision and increase discomfort or bleeding risk.

🔷High Fowler’s may also be excessive immediately postoperatively if it causes neck strain.

High Fowler’s with neck in a neutral position

🔷A neutral neck position is appropriate, but Semi-Fowler’s is usually preferred to reduce swelling without excessive strain.

🔷High Fowler’s can increase pressure and discomfort at the surgical site.

Semi-Fowler’s with neck extended

🔷Semi-Fowler’s is appropriate, but the neck should not be extended.

🔷Extension can pull on the incision and increase the risk of wound stress.

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Answer 10

Correct Answers:

Hyperpigmentation

Rationale :

🔶 Addison’s disease causes adrenocortical insufficiency, leading to decreased cortisol and often decreased aldosterone.

🔶 Low cortisol causes the pituitary gland to release more ACTH in an attempt to stimulate the adrenal glands.

🔶 Increased ACTH is associated with increased melanocyte stimulation, which causes hyperpigmentation.

🔶 Hyperpigmentation is commonly seen in skin folds, pressure areas, scars, elbows, knees, and mucous membranes.

🔶 The nurse should also expect fatigue, weight loss, hypotension, hyponatremia, and hyperkalemia.

Intention tremors

🔶Intention tremors are more associated with neurologic disorders such as cerebellar dysfunction.

🔶 They are not an expected manifestation of Addison’s disease.

Hirsutism

🔶 Hirsutism is more associated with excess androgen states such as Cushing’s syndrome or polycystic ovarian syndrome.

🔶 Addison’s disease involves decreased adrenal hormone production.

Purple striations

🔶Purple striations are classic for Cushing’s syndrome due to excess cortisol and skin thinning.

🔶 Addison’s disease is related to cortisol deficiency, not cortisol excess.

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Potential Order	anticipated	contraindicated
Monitor vital signs daily.
Encourage the client to attend group activities.
Reduce the level of stimuli in the client's environment.
Weigh the client daily.
Provide the client with a high-calorie, high protein shake every hour.
Provide frequent rest periods .

QLexNursing

2 :
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

3 :
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

4 :
A nurse is planning care for a client.

Correct Answers

5 :
A nurse is caring for a client who has end-stage kidney disease who will soon begin hemodialysis treatments. Which of the following restrictions should the nurse discuss with the client that may impact quality of life? (Select All that Apply.)

6 :
A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

7 :
A nurse is caring for a young adult client who is being evaluated for antisocial personality disorder.

Correct Highlights :

8 :
A nurse is admitting a client to the mental health unit.

Answer Options

9 :
A nurse is caring for a client who is 8hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

10 :
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?

QLexNursing

2 : A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

3 : A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

4 : A nurse is planning care for a client.

Correct Answers

5 : A nurse is caring for a client who has end-stage kidney disease who will soon begin hemodialysis treatments. Which of the following restrictions should the nurse discuss with the client that may impact quality of life? (Select All that Apply.)

6 : A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

7 : A nurse is caring for a young adult client who is being evaluated for antisocial personality disorder.

Correct Highlights :

8 : A nurse is admitting a client to the mental health unit.

Answer Options

9 : A nurse is caring for a client who is 8hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

10 : A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?

2 :
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

3 :
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

4 :
A nurse is planning care for a client.

5 :
A nurse is caring for a client who has end-stage kidney disease who will soon begin hemodialysis treatments. Which of the following restrictions should the nurse discuss with the client that may impact quality of life? (Select All that Apply.)

6 :
A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan?

7 :
A nurse is caring for a young adult client who is being evaluated for antisocial personality disorder.

8 :
A nurse is admitting a client to the mental health unit.

9 :
A nurse is caring for a client who is 8hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

10 :
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?