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nursing 3 exam 1 study guide brunner 51, brunner 31

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1

After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias?

Serum potassium level

The nurse should monitor the client's potassium level because during periods of acidosis, potassium leaves the cell, causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser effect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1444

2

A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important?

Control blood glucose levels.

Controlling blood glucose levels and any hypertension can prevent or delay the development of diabetic nephropathy. Drinking plenty of fluids does not prevent diabetic nephropathy. Taking antidiabetic drugs regularly may help to control blood glucose levels, but it is the control of these levels that is most important. A high-fiber diet is unrelated to the development of diabetic nephropathy.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1452

3

NPH is an example of which type of insulin?

Intermediate-acting

Explanation:NPH is intermediate-acting insulin

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1428

4

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which of the following factors as a cause of type 1 diabetes?

Presence of autoantibodies against islet cells

Explanation: There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1418

5

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient?

Signs of hypoglycemia

Explanation: The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested. Polyuria, polydipsia, and blurred vision are the symptoms of diabetes mellitus.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1433

6

The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet?

Sensory neuropathy

Explanation: ) Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1454

7

A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:

suggest referral to a sex counselor or other appropriate professional

.Explanation: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1454

8

A client with type 1 diabetes mellitus is receiving short-acting insulin to maintain control of blood glucose levels. In providing glucometer instructions, the nurse would instruct the client to use which site for most accurate findings?

Finger

Explanation: Even though the fingertips have a higher number of nerve endings, this site provides the most accurate blood sugar reading. Alternate sites, such as upper arm, forearm, and thighs are regarded as lagging test sites and are not an option for people who require tight glucose control.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1426

9

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client’s glycosylated hemoglobin test results. Which result would indicate to the nurse that the client’s blood glucose level has been well controlled?

6.5%

Explanation: Normally, the level of glycosylated hemoglobin is less than 7%. Thus, a level of 6.5% would indicate that the client’s blood glucose level is well controlled. According to the American Diabetes Association, a glycosylated hemoglobin of 7% is equivalent to an average blood glucose level of 150 mg/dl. Thus, a level of 7.5% would indicate less control. Amount of 8% or greater indicate that control of the client’s blood glucose level has been inadequate during the previous 2 to 3 months.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1421

10

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend?

consuming a low-carbohydrate, high-protein diet and avoiding fasting.

Explanation: To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1442

11

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin

Explanation: Metformin is a biguanide and along with the thiazolidinediones (rosiglitazone and pioglitazone) are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1434

12

Which instruction about insulin administration should a nurse give to a client?

" Always follow the same order when drawing the different insulins into the syringe."

Explanation: The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1438

13

A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

9 units regular insulin and 21 units neutral protamine Hagedorn (NPH).

Explanation: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 units of NPH and 9

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1438

14

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient?

Hypoglycemia

Explanation: The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1434

15

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites?

Insulin is absorbed more rapidly at abdominal injection sites than at other sites

Explanation: Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1438

16

The nurse is educating a patient about the benefits of fruit versus fruit juice in the diabetic diet. The patient states, “What difference does it make if you drink the juice or eat the fruit? It is all the same.” What is the best response by the nurse?

“Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption.”

Explanation:Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1424

17

What is the only insulin that can be given intravenously?

Regular

Explanation:Insulins other than regular are in suspensions that could be harmful if administered IV.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1428

18

Insulin is secreted by which of the following types of cells?

Beta cells

Explanation: Insulin is secreted by the beta cells, in the islets of Langerhans of the pancreas. In diabetes, cells may stop responding to insulin, or the pancreas may decrease insulin secretion or stop insulin production completely. Melanocytes are what give the skin its pigment. Neural cells transmit impulses in the brain and spinal cord. Basal cells are a type of skin cell.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1417

19

A nurse is preparing to administer insulin to a child who's just been diagnosed with type 1 diabetes. When the child's mother stops the nurse in the hall, she's crying and anxious to talk about her son's condition. The nurse's best response is:

"I'm going to give your son some insulin. Then I'll be happy to talk with you."

Explanation: Attending to the mother's needs is a critical part of caring for a sick child. In this case however, administering insulin in a prompt manner supersedes the mother's needs. By informing the mother that she's going to administer the insulin and will then make time to talk with her, the nurse recognizes the mother's needs as legitimate. She provides a reasonable response while attending to the priority of administering insulin as soon as possible. Telling the mother that she can't talk with her or telling her to wait for the physician could increase the mother's fear and anxiety. The nurse shouldn't tell the mother that everything will be fine; the nurse doesn't know that everything will be fine.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1436

20

A client with diabetes mellitus is receiving an oral antidiabetic agent. Which of the following aspects should the nurse observe when caring for this client?

Signs of hypoglycemia

Explanation: The nurse should observe the client receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested. Observe the client receiving an oral antidiabetic agent for signs of hypoglycemia.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1459

21

A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate?

Albumin

Explanation: Albumin is one of the most important blood proteins that leak into the urine. Although small amounts may leak undetected for years, its leakage into the urine is among the earliest signs that can be detected. Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria but in fewer than 5% of people without microalbuminuria (Chart 51-10). The urine should be checked annually for the presence of microalbumin.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1451

22

Which of the following should be included in the teaching plan for a patient receiving glargine (Lantus),"peakless" basal insulin?

Do not mix with other insulins

Explanation: Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa. Glargine is absorbed very slowly over a 24-hour period and can be given once a day. Glargine is a "peakless" basal insulin that is absorbed very slowly over a 24-hour period.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1429

23

A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason?

Underlying problem of insulin resistance

Explanation: Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant. Urologic complications or the need for exocrine enzymatic drainage are not reasons for not offering pancreas transplant to clients with type 2 diabetes. Any transplant requires lifelong immunosuppressive drug therapy and is not the factor.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1417

24

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient?

Signs of hypoglycemia

Explanation: The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested. Polyuria, polydipsia, and blurred vision are the symptoms of diabetes mellitus.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1433

25

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

Using sterile technique during the dressing change

Explanation: The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk of injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1455

26

An older adult patient that has diabetes type 2 comes to the emergency department with second-degree burns to the bottom of both feet and states, “I didn’t feel too hot but my feet must have been too close to the heater.” What does the nurse understand is most likely the reason for the decrease in temperature sensation?

Peripheral neuropathy

Explanation: As the neuropathy progresses, the feet become numb. In addition, a decrease in proprioception (awareness of posture and movement of the body and of position and weight of objects in relation to the body) and a decreased sensation of light touch may lead to an unsteady gait. Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1453

27

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?

Regular

Explanation: Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting insulin. Regular insulin is the only insulin approved for IV use.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1428

28

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

Sweating, tremors, and tachycardia

Explanation: Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1441

29

The nurse is administering lispro (Humalog) insulin. Based on the onset of action, how soon should the nurse administer the injection prior to breakfast?

10 to 15 minutes

Explanation:The onset of action of rapid-acting Humalog is within 10 to 15 minutes. It is used for rapid reduction of glucose level.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1428

30

A 53-year-old client is brought to the ED, via squad, where you practice nursing. He is demonstrating fast, deep, labored breathing and has a fruity odor to his breath. He has a history of type 1 diabetes. What could be the cause of his current serious condition?

Ketoacidosis

Explanation: Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. The most likely cause is ketoacidosis. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level. The most likely cause is ketoacidosis.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1419

31

A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

Deficient knowledge (treatment regimen)

Explanation: The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client's health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn't warranted.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1428

32

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well-controlled?

6.5%

Explanation: Normally the level of glycosylated hemoglobin is less than 7%. Thus a level of 6.5% would indicate that the client's blood glucose level is well-controlled. According to the American Diabetes Association, a glycosylated hemoglobin of 7% is equivalent to an average blood glucose level of 150 mg/dL. Thus, a level of 7.5% would indicate less control. Amount of 8% or greater indicate that control of the client's blood glucose level has been inadequate during the previous 2 to 3 months.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1421

33

A client with diabetes mellitus is receiving an oral antidiabetic agent. Which of the following aspects should the nurse observe when caring for this client?

Signs of hypoglycemia

Explanation: The nurse should observe the client receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested. Observe the client receiving an oral antidiabetic agent for signs of hypoglycemia

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1459

34

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse is most accurate in stating:

"It tells us about your sugar control for the last 3 months."

Explanation: The nurse is providing accurate information to the client when she states that the glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting period before blood is drawn. The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin coverage.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1427

35

A patient with diabetes mellitus is prescribed to switch from animal to synthesized human insulin. Which of the following factors should the nurse monitor when caring for the patient?

Low blood glucose levels

Explanation: Patients who switch from animal to synthesized human insulin should be monitored for low blood glucose levels initially because the human form of insulin is used more effectively. Human insulin causes fewer allergic reactions than insulin obtained from animal sources. Polyuria and hypertonicity are the symptoms of diabetes mellitus.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1430

36

A male client, aged 42, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client's consumption of carbohydrates

Explanation: While assessing a client, it is important to note the client's consumption of carbohydrates because he has high blood sugar. Although other factors such as the client's mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not as important to information related to the client's to be noted in a client with high blood sugar

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1422

37

During a follow-up visit 3 months following a new diagnosis of type 2 diabetes, a patient reports exercising and following a reduced-calorie diet. Assessment reveals that the patient has only lost 1 pound and did not bring the glucose-monitoring record. Which of the following tests will the nurse plan to obtain?

Glycosylated hemoglobin level

Explanation: Glycosylated hemoglobin is a blood test that reflects average blood glucose levels over a period of approximately 2 to 3 months. When blood glucose levels are elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycated hemoglobin level becomes.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1427

38

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin

Explanation: Metformin is a biguanide and along with the thiazolidinediones (rosiglitazone and pioglitazone) are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1434

39

A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of “sick days.” The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse’s best response?

Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy.

Explanation: ) Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1427

40

The nurse is teaching a patient about self-administration of insulin and mixing of regular and neutral protamine Hagedorn (NPH) insulin. Which of the following is important to include in the teaching plan?

When mixing insulin, the regular insulin is drawn up into the syringe first.

Explanation: When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before drawing into the syringe. The American Diabetic Association (ADA) recommends that the regular insulin be drawn up first. The most important issues are (1) that patients are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) that patients not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1438

41

A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client:

has type 2 diabetes

Explanation: Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. Pregnant and lactating women aren't ... (more) Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. Pregnant and lactating women aren't ordered oral antidiabetic agents because the effect on the fetus or breast-fed infant is uncertain

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1432

42

Which of the following is true regarding gestational diabetes?

A glucose challenge test should be performed between 24 to 28 weeks

Explanation: A glucose challenge test should be performed between 24 to 48 weeks. It occurs in 2 to 5% of all pregnancies. Onset is usually in the second or third trimester. There is an above-n ... (more) A glucose challenge test should be performed between 24 to 48 weeks. It occurs in 2 to 5% of all pregnancies. Onset is usually in the second or third trimester. There is an above-normal risk for perinatal complications.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1418

43

An older adult patient that has diabetes type 2 comes to the emergency department with second-degree burns to the bottom of both feet and states, “I didn’t feel too hot but my feet must have been too close to the heater.” What does the nurse understand is most likely the reason for the decrease in temperature sensation?

Peripheral neuropathy

Explanation: As the neuropathy progresses, the feet become numb. In addition, a decrease in proprioception (awareness of posture and movement of the body and of position and weight of objects i ... (more) As the neuropathy progresses, the feet become numb. In addition, a decrease in proprioception (awareness of posture and movement of the body and of position and weight of objects in relation to the body) and a decreased sensation of light touch may lead to an unsteady gait. Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1453

44

A client with diabetes is receiving an oral anti diabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin

Explanation: Metformin is a biguanide and, along with the thiazolidinediones (rosiglitazone and pioglitazone), are categorized as insulin sensitizers; they help tissues use available insulin mo ... (more) Metformin is a biguanide and, along with the thiazolidinediones (rosiglitazone and pioglitazone), are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide, which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1434

45

Which of the following clinical characteristics is associated with Type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus [IDDM])?

Presence of islet cell antibodies

Explanation: Individuals with type 1 diabetes often have islet cell antibodies. Individuals with type 1 diabetes are usually thin or demonstrate recent weight loss at the time of diagnosis. Ind ... (more) Individuals with type 1 diabetes often have islet cell antibodies. Individuals with type 1 diabetes are usually thin or demonstrate recent weight loss at the time of diagnosis. Individuals with type 1 diabetes are ketosis-prone when insulin is absent. Individuals with type 1 diabetes need insulin to preserve life. (less)

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1418

46

A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. Which of the following symptoms would she include when reviewing classic symptoms associated with diabetes?

a) Increased weight gain, increased appetite, and increased thirst
b) Loss of appetite, increased urination, and dehydration
c) Increased weight loss, increased dehydration, and increased fatigue
d) Increased thirst, increased hunger, and increased urination

Increased thirst, increased hunger, and increased urination

Explanation:The three classic symptoms of both types of diabetes mellitus are polyuria, polydipsia, and polyphagia. Weight loss, dehydration, and fatigue are additional symptoms.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1420

47

Exercise lowers blood glucose levels. Which of the following are the physiologic reasons that explain this statement. Select all that apply.

a) Increases glucose uptake by body muscles
b) Increases lean muscle mass
c) Increases resting metabolic rate as muscle size increases
d) Decreases the levels of high-density lipoproteins
e) Decreases total cholesterol

• Increases lean muscle mass
• Increases resting metabolic rate as muscle size increases
• Decreases total cholesterol
• Increases glucose uptake by body muscles

Explanation:All of the options are benefits of exercise except the effect of decreasing the levels of HDL. Exercise increases the levels of HDL.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1425

48

The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet?

a) Nephropathy
b) Autonomic neuropathy
c) Retinopathy
d) Sensory neuropathy

Sensory neuropathy

Explanation: Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivit ... (more) Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1454

49

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

a) Polyuria, polydipsia, polyphagia, and weight loss
b) Coma, anxiety, confusion, headache, and cool, moist skin
c) Kussmaul's respirations, dry skin, hypotension, and bradycardia
d) Polyuria, polydipsia, hypotension, and hypernatremia

Coma, anxiety, confusion, headache, and cool, moist skin

Explanation: Signs and symptoms of hypoglycemia (indicated by a blood glucose level of 45 mf/dl) include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors ... (more) Signs and symptoms of hypoglycemia (indicated by a blood glucose level of 45 mf/dl) include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul's respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1441

50

Which statement indicates that a client with diabetes mellitus understands proper foot care?

"I'll wear cotton socks with well-fitting shoes."

Explanation: The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, h ... (more) The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1455

51

The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?

a) Creates an overall feeling of well-being and lowers risk of depression
b) Increases ability for glucose to get into the cell and lowers blood sugar
c) Decreases need for pancreas to produce more cells
d) Decreases risk of developing insulin resistance and hyperglycemia

Increases ability for glucose to get into the cell and lowers blood sugar

Explanation: Exercise increases trans membrane glucose transporter levels in the skeletal muscles. This allows the glucose to leave the blood and enter into the cells where it can be used as fu ... (more) Exercise increases trans membrane glucose transporter levels in the skeletal muscles. This allows the glucose to leave the blood and enter into the cells where it can be used as fuel. Exercise can provide an overall feeling of well-being but is not the primary purpose of including in the daily routine of diabetic clients. Exercise does not stimulate the pancreas to produce more cells. Exercise can promote weight loss and decrease risk of insulin resistance but not the primary reason for adding to daily routine.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1425

52

A 16-year-old patient newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The patient is upset because friends frequently state, “You look anorexic.” Which of the following statements would be the best response by the nurse to help this patient understand the cause of weight loss due to this condition?

a) "Your body is using protein and fat for energy instead of glucose."
b) "I will refer you to a dietician who can help you with your weight."
c) "You may be having undiagnosed infections causing you to lose extra weight."
d) “Don’t worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism.”

" Your body is using protein and fat for energy instead of glucose."

Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin s ... (more) Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1422

53

The nurse is educating the diabetic client on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include?

a) Take half the usual dose of insulin until symptoms resolve.
b) Increase frequency of glucose self-monitoring.
c) Do not take insulin if not eating.
d) Decrease food intake until nausea passes

Increase frequency of glucose self-monitoring

Explanation: Minor illnesses such as influenza can present a special challenge to a diabetic client. The body’s need for insulin increases during illness. Therefore, the client should ta ... (more) Minor illnesses such as influenza can present a special challenge to a diabetic client. The body’s need for insulin increases during illness. Therefore, the client should take the prescribed insulin dose, increase the frequency of glucose monitoring, and maintain adequate fluid intake to counteract the dehydrating effects of hyperglycemia. Clear liquids and juices are encouraged. Taking less than normal dose of insulin may lead to ketoacidosis

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1426

54

A 60-year-old patient comes to the ED with complaints of weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the patient has diabetes. Which of the following classic symptoms should the nurse watch for to confirm the diagnosis of diabetes?

a) Fatigue
b) Dizziness
c) Increased hunger
d) Numbness

Increased hunger

Explanation: The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms incl ... (more) The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1420

55

Which instruction about insulin administration should a nurse give to a client?

a) "Shake the vials before withdrawing the insulin."
b) "Store unopened vials of insulin in the freezer at temperatures well below freezing."
c) "Always follow the same order when drawing the different insulins into the syringe."
d) "Discard the intermediate-acting insulin if it appears cloudy."

"Always follow the same order when drawing the different insulins into the syringe."

Explanation: The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting frot ... (more) The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal.

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1438

56

The nurse is educating a patient about the benefits of fruit versus fruit juice in the diabetic diet. The patient states, “What difference does it make if you drink the juice or eat the fruit? It is all the same.” What is the best response by the nurse?

a) “Eating the fruit is more satisfying than drinking the juice. You will get full faster.”
b) “Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption.”
c) “Eating the fruit will give you more vitamins and minerals than the juice will.”
d) “The fruit has less sugar than the juice.”

“Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption.”

Explanation:Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1424

57

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

The client has eaten and has not taken or received insulin

Explanation: If the client has eaten and has not taken or received insulin, DKA is more likely to develop. Hypoglycemia is more likely to develop if the client has not consumed food and continu ... (more) If the client has eaten and has not taken or received insulin, DKA is more likely to develop. Hypoglycemia is more likely to develop if the client has not consumed food and continues to take insulin or oral antidiabetic medications, if the client has not consumed sufficient calories, or if client has been exercising more than

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1443

58

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client’s consumption of carbohydrates

Explanation: While assessing a client, it is important to note the client’s consumption of carbohydrates because he has high blood sugar. Although other factors such as the client’ ... (more) While assessing a client, it is important to note the client’s consumption of carbohydrates because he has high blood sugar. Although other factors such as the client’s mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not as important to information related to the client’s to be noted in a client with high blood sugar

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1422

59

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor?

Hypoglycemia

Explanation:The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia while maintaining a high quality of life

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1421

60

Lispro (Humalog) is an example of which type of insulin?

Rapid-acting

Explanation:Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus)

Chapter 51: Assessment and Management of Patients With Diabetes - Page 1428

61

A female client, aged 82 years, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine?

a) A possible adverse effect of blood pressure medicine is dizziness when you stand.
b) Take the medicine on an empty stomach.
c) A severe drop in blood pressure is possible.
d) There are no adverse effects from blood pressure medicine.

A possible adverse effect of blood pressure medicine is dizziness when you stand

Explanation: A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. You would ... (more) A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. You would not teach the client to take the medicine on an empty stomach.

Chapter 31: Assessment and Management of Patients With Hypertension - Page 868

62

A patient with long-standing hypertension is admitted to the hospital with hypertensive urgency. The physician orders a chest x-ray, which reveals an enlarged heart. What diagnostic test does the nurse anticipate preparing the patient for to determine left ventricular enlargement?

a) Stress test
b) Echocardiography
c) Tilt-table test
d) Cardiac catheterization

Echocardiography

Explanation:Left ventricular hypertrophy can be assessed by echocardiography, but not by any of the other measures listed

Chapter 31: Assessment and Management of Patients With Hypertension - Page 864

63

A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension?

a) Secondary
b) Primary
c) Malignant
d) Essential

Secondary

Explanation:Secondary hypertension is elevated BP that results from or is secondary to some other disorder. This type of hypertension is not primary, essential, or malignant

Chapter 31: Assessment and Management of Patients With Hypertension - Page 861

64

The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?

a) Kidneys and autonomic nervous system
b) Brain and sympathetic nervous system
c) Lung and arteries
d) Heart and blood vessels

Heart and blood vessels

Explanation: Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP= CO (cardiac output)× PR (peripheral resistance). To ... (more) Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP= CO (cardiac output)× PR (peripheral resistance). To highlight the mechanism of cardiac output, a heart would be on the visual aid and blood vessels.

Chapter 31: Assessment and Management of Patients With Hypertension - Page 655

65

A nurse is teaching a 38-year-old man with newly diagnosed hypertension who asks if there is any harm in stopping his antihypertensive medication if he decides to discontinue it. The correct reply addresses the consequence of stopping antihypertensive medications abruptly. Which of the following statements from the nurse would be appropriate?

a) "Rebound hypotension can occur."
b) "Postural hypertension can occur."
c) "Rebound hypertension can occur."
d) "Postural hypotension can occur."

"Rebound hypertension can occur."

Explanation: Clients need to be informed that rebound hypertension can occur if they stop antihypertensive medications suddenly. This can be extremely dangerous and have serious consequences. H ... (more) Clients need to be informed that rebound hypertension can occur if they stop antihypertensive medications suddenly. This can be extremely dangerous and have serious consequences. Hypotension would not be a problem with discontinuation of antihyperstensive medications

Chapter 31: Assessment and Management of Patients With Hypertension - Page 872

66

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

a) "If I include less fat in my diet, I'll lower my blood pressure."
b) "I should eliminate caffeine from my diet to lower my blood pressure."
c) "Limiting my salt intake to 2 grams per day will improve my blood pressure."
d) "A glass of red wine each day will lower my blood pressure."

"Limiting my salt intake to 2 grams per day will improve my blood pressure."

Explanation: To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatmen ... (more) To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Chronic, moderate caffeine intake and fat intake don't affect blood pressure

Chapter 31: Assessment and Management of Patients With Hypertension - Page 865

67

The nurse is caring for an 82-year-old male client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP?

a) Decrease in cardiac output
b) Decrease in blood volume
c) Increase in calcium intake
d) Loss of arterial elasticity

Loss of arterial elasticity

Explanation: In older clients, systolic BP may be elevated because of loss of arterial elasticity (arteriosclerosis). Systolic BP would not become elevated by a decrease in blood volume, an inc ... (more) In older clients, systolic BP may be elevated because of loss of arterial elasticity (arteriosclerosis). Systolic BP would not become elevated by a decrease in blood volume, an increase in calcium intake, or a decrease in cardiac output

Chapter 31: Assessment and Management of Patients With Hypertension - Page 863

68

It is appropriate for the nurse to recommend smoking cessation for patients with hypertension because nicotine

a) decreases circulating blood volume.
b) increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.
c) increases the heart rate, constricts arterioles, and increases the heart's ability to eject blood.
d) decreases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.

increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.

Explanation: The nurse recommends smoking cessation for patients with hypertension because nicotine raises the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. ... (more) The nurse recommends smoking cessation for patients with hypertension because nicotine raises the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. Reduced oral fluids decrease the circulating blood volume

Chapter 31: Assessment and Management of Patients With Hypertension - Page 871

69

Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period.

140, 90

Explanation: According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159, or a diastolic pressure o ... (more) According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159, or a diastolic pressure of 90 to 99. Pressure of 130 systolic and 80 diastolic falls within the normal range for an adult. Pressure of 110 systolic and 60 diastolic falls within the normal range for an adult. Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult

Chapter 31: Assessment and Management of Patients With Hypertension - Page 862

70

Which of the following client scenarios would be correct for the nurse to identify as a client with secondary hypertension?

A client diagnosed with kidney disease

Explanation: Secondary hypertension is an elevated blood pressure that results from or is secondary to some other disorder such as kidney disease, a tumor of the adrenal medulla, or atheroscler ... (more) Secondary hypertension is an elevated blood pressure that results from or is secondary to some other disorder such as kidney disease, a tumor of the adrenal medulla, or atherosclerosis. Depression alone is typically not associated with hypertension. Advanced age and alcohol intake are considered factors for essential hypertension

Chapter 31: Assessment and Management of Patients With Hypertension - Page 862

71

Which of the following would be inconsistent as a component of metabolic syndrome?

Hypotension

Explanation:Diabetes, obesity, dyslipidemia, hypertension, and elevated triglycerides are components of metabolic syndrome. Hypotension is not a component of metabolic syndrome.

Chapter 31: Assessment and Management of Patients With Hypertension - Page 862

72

The nurse is administering medications on a medical surgical unit. A patient is ordered to receive 40 mg of oral Corgard (nadolol) for the treatment of hypertension. Prior to administering the medication, the nurse should complete which of the following?

Checking the patient’s heart rate

Explanation: Corgard is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in patients with tachycardia and an elevated blood pressure (BP). The nurse should check ... (more) Corgard is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in patients with tachycardia and an elevated blood pressure (BP). The nurse should check the patient’s heart rate (HR) prior to administering Corgard to ensure that the patient’s pulse rate is not below 60 (beats per minute (bpm). The other interventions are not indicated prior to administering a beta-blocker medication.

Chapter 31: Assessment and Management of Patients With Hypertension - Page 867

73

A client diagnosed with hypertension begins drug therapy using an antihypertensive agent. The nurse instructs the client’s spouse to remove any objects in the home that can lead to falls. The nurse knows that the teaching has been successful when the client restates which of the following?

"Antihypertensive drugs can lead to falls.”

Explanation: One of the side effects of all antihypertensive drugs is hypotension, which can lead to falls. A major concern regarding side effects of all antihypertensive drugs is hypotension, ... (more) One of the side effects of all antihypertensive drugs is hypotension, which can lead to falls. A major concern regarding side effects of all antihypertensive drugs is hypotension, which can lead to falls

Chapter 31: Assessment and Management of Patients With Hypertension - Page 872

74

A nurse is caring for a client with hypertension. The physician orders furosemide (lasix) 2 mg/kg to be given intravenously. The client weighs 24 kg. The medication comes in a single-use vial that contains 40 mg in 4 mL (10 mg/mL). How much will the nurse draw up for this client's dose?

4.8 mL

Explanation:The formula is as follows: 24Kg X 2 mg = 48 mg total dose 48 mg / 10mg/mL = 4.8 mL amount to be drawn up

Chapter 31: Assessment and Management of Patients With Hypertension - Page 867

75

A 77-year-old client has newly diagnosed stage 2 hypertension. The physician has prescribed a thiazide and an angio-converting enzyme inhibitor. About what is the nurse most concerned?

Postural hypotension and resulting injury

Explanation: Antihypertensive medication can cause hypotension, especially postural hypotension that may result in injury. Rebound hypertension occurs when antihypertensive medication is stoppe ... (more) Antihypertensive medication can cause hypotension, especially postural hypotension that may result in injury. Rebound hypertension occurs when antihypertensive medication is stopped abruptly. Sexual dysfunction may occur, especially with beta blockers, but other medications are available should this problem ensue. This is not immediately a priority concern. Antihypertensive medications do not usually cause postural hypertension.

Chapter 32: Assessment and Management of Patients With Hypertension, page 899.

76

According to the classification of hypertension diagnosed in the older adult, hypertension that can be attributed to an underlying cause is termed ?

secondary

Explanation: Secondary hypertension may be caused by a tumor of the adrenal gland (eg, pheochromocytoma). Primary hypertension has no known underlying cause. Essential hypertension has no known ... (more) Secondary hypertension may be caused by a tumor of the adrenal gland (eg, pheochromocytoma). Primary hypertension has no known underlying cause. Essential hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg

Chapter 31: Assessment and Management of Patients With Hypertension - Page 862

77

A client with newly diagnosed hypertension asks what she can do to decrease the risk for related cardiovascular problems. Which of the following risk factors is not modifiable by the client?

Age

Explanation: Age and family history for cardiovascular disease are risk factors that cannot be changed. Obesity, inactivity, and disylipidemia are risk factors that can be improved by the clien ... (more) Age and family history for cardiovascular disease are risk factors that cannot be changed. Obesity, inactivity, and disylipidemia are risk factors that can be improved by the client through dietary changes, exercise, and other healthy lifestyle choices.

Chapter 32: Assessment and Management of Patients With Hypertension, page 892.

78

A patient is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The patient’s blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV Nitropress (nitroprusside). Upon assessment, which of the following patient findings requires immediate intervention by the nurse?

Left arm numbness and weakness

Explanation: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may oc ... (more) Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of left arm numbness and weakness may indicate the patient is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP and requires immediate interventions. A urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes

Chapter 31: Assessment and Management of Patients With Hypertension - Page 873

79

An 87-year-old client was just recently diagnosed with prehypertension. She is to meet with a dietitian and return for a follow-up with her cardiologist in 6 months. As her nurse, what would you expect her treatment to include?

Nonpharmacological interventions

Explanation:Nonpharmacologic interventions are used for clients with prehypertension

Chapter 31: Assessment and Management of Patients With Hypertension - Page 861

80

A nurse is providing education about hypertension to a community group. One client reports that his doctor has diagnosed him with hypertension, but that he feels just fine. He asks, “What would happen if I did not treat my hypertension?” Which of the following are possible consequences of untreated hypertension? Choose all that apply

• Myocardial infarction
• Coronary artery disease
• Stroke
Explanation: People with hypertension may remain asymptomatic for many years. When specific signs and symptoms appear, however, they usually indicate vascular damage. Coronary artery disease wi ... (more) People with hypertension may remain asymptomatic for many years. When specific signs and symptoms appear, however, they usually indicate vascular damage. Coronary artery disease with angina and myocardial infarction are common consequences of hypertension. Cerebrovascular involvement may lead to a stroke. Tension pneumothorax and pancreatitis are not directly related to hypertension

Chapter 31: Assessment and Management of Patients With Hypertension - Page 863

81

The nurse is caring for an 82-year-old male client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP?

a) Decrease in cardiac output
b) Decrease in blood volume
c) Loss of arterial elasticity
d) Increase in calcium intake

Loss of arterial elasticity

Explanation: In older clients, systolic BP may be elevated because of loss of arterial elasticity (arteriosclerosis). Systolic BP would not become elevated by a decrease in blood volume, an inc ... (more) In older clients, systolic BP may be elevated because of loss of arterial elasticity (arteriosclerosis). Systolic BP would not become elevated by a decrease in blood volume, an increase in calcium intake, or a decrease in cardiac output

Chapter 31: Assessment and Management of Patients With Hypertension - Page 863

82

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. Which of the following are risk factors for cardiovascular problems in clients with hypertension? Choose all that apply.

a) Gallbladder disease
b) Frequent upper respiratory infections
c) Diabetes mellitus
d) Smoking
e) Physical inactivity

• Diabetes mellitus
• Smoking
• Physical inactivity

Explanation: Risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, ... (more) Risk factors for cardiovascular problems in clients with hypertension include smoking, dyslipidemia, diabetes mellitus, impaired renal function, obesity, physical inactivity, age, and family history

Chapter 31: Assessment and Management of Patients With Hypertension - Page 864

83

A nurse is teaching a 38-year-old man with newly diagnosed hypertension who asks if there is any harm in stopping his antihypertensive medication if he decides to discontinue it. The correct reply addresses the consequence of stopping antihypertensive medications abruptly. Which of the following statements from the nurse would be appropriate?

a) "Rebound hypotension can occur."
b) "Rebound hypertension can occur."
c) "Postural hypotension can occur."
d) "Postural hypertension can occur."

"Rebound hypertension can occur."

Explanation: Clients need to be informed that rebound hypertension can occur if they stop antihypertensive medications suddenly. This can be extremely dangerous and have serious consequences. H ... (more) Clients need to be informed that rebound hypertension can occur if they stop antihypertensive medications suddenly. This can be extremely dangerous and have serious consequences. Hypotension would not be a problem with discontinuation of antihyperstensive medications

Chapter 31: Assessment and Management of Patients With Hypertension - Page 872

84

The nurse is caring for a client newly diagnosed with secondary hypertension. Which of the following conditions contributes to the development of secondary hypertension?

a) Renal disease
b) Calcium deficit
c) Acid-based imbalance
d) Hepatic function

Renal disease

Explanation: Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldo ... (more) Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoietin alfa [Epogen]), and coarctation of the aorta. High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attacks, strokes, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension.

Chapter 31: Assessment and Management of Patients With Hypertension - Page 862

85

A patient is flying overseas for 1 week for business and packed antihypertensive medications in a suitcase. After arriving at the intended destination, the patient found that the luggage had been stolen. If the patient cannot take the medication, what condition becomes a concern?

a) Isolated systolic hypertension
b) Left ventricular hypertrophy
c) Rebound hypertension
d) Angina

Rebound hypertension

Explanation: Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Thus, patients should be advised to have an adequate supply o ... (more) Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Thus, patients should be advised to have an adequate supply of medication, particularly when traveling and in case of emergencies such as natural disasters. If traveling by airplane, patients should pack the medication in their carry-on luggage

Chapter 31: Assessment and Management of Patients With Hypertension - Page 872

86

When treating hypertensive emergencies, the nurse identifies the most appropriate route of administration for antihypertensive agents as being which of the following?

a) Oral
b) Sublingual
c) Continuous IV infusion
d) Intramuscular

Continuous IV infusion

Explanation: The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the ... (more) The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the sublingual and IM routes as their absorption and dynamics are unpredictable. The oral route would not have as quick an onset as a continuous IV infusion

Chapter 31: Assessment and Management of Patients With Hypertension - Page 873

87

A client, newly prescribed a low-sodium diet due to hypertension, is asking for help with meal choices. The client provides four meal choices, which are favorites. Which selection would be best?

a) Toasted cheese sandwich on whole wheat toast with tomato soup
b) Hot dog with ketchup and relish on whole wheat bun
c) Creamed chipped beef over toast with mashed potatoes
d) Green pepper stuffed with diced tomatoes and chicken

Green pepper stuffed with diced tomatoes and chicken

Explanation: Fresh vegetables are low in sodium with diced tomatoes (fresh) and chicken is a good low-sodium, high vegetable and protein selection. Cheese and soup (tomato and creamed) are high ... (more) Fresh vegetables are low in sodium with diced tomatoes (fresh) and chicken is a good low-sodium, high vegetable and protein selection. Cheese and soup (tomato and creamed) are high in sodium. Processed meats such as a hot dog and condiments such as ketchup are high in sodium

Chapter 31: Assessment and Management of Patients With Hypertension - Page 865

88

A female client, aged 82, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine?

a) A possible adverse effect of blood pressure medicine is dizziness when you stand.
b) There are no adverse effects from blood pressure medicine.
c) Take the medicine on an empty stomach.
d) A severe drop in blood pressure is possible.

A possible adverse effect of blood pressure medicine is dizziness when you stand

Explanation: A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. You would ... (more) A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. You would not teach the client to take the medicine on an empty stomach

Chapter 31: Assessment and Management of Patients With Hypertension - Page 868

89

The nurse is caring for a client with hypertension. The nurse is correct to realize that a 24-hour urine is ordered to determine if the cause of hypertension is related to the dysfunction of which of the following?

a) The thymus
b) The adrenal gland
c) The pituitary gland
d) The thyroid gland

The adrenal gland

Explanation: The 24-hour urine collection specimen is ordered to determine dysfunction of the adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are not evaluat ... (more) The 24-hour urine collection specimen is ordered to determine dysfunction of the adrenal gland. The 24-hour urine detects elevated catecholamines. The other options are not evaluated by a 24-hour urine

Chapter 31: Assessment and Management of Patients With Hypertension - Page 864

90

A nurse is teaching about lifestyle modifications to a group of clients with known hypertension. Which of the following statements would the nurse include in the education session?

a) Maintain a waist circumference of 45 (men) and 40 (women) inches or less.
b) Limit alcohol consumption to no more that 3 drinks per day.
c) Maintain a body mass index between 30 and 35.
d) Engage in aerobic activity at least 30 minutes/day most days of the week.

Engage in aerobic activity at least 30 minutes/day most days of the week.

Explanation: Recommended lifestyle modifications to prevent and manage hypertension include maintaining a normal body mass index (about 24; greater than 25 is considered overweight), maintaining a waist circumference of less than 40 inches for men and 35 inches for women, limiting alcohol intake to no more than 2 drinks for men and 1 drink for women per day, and engaging in aerobic activity at least 30 minutes per day most days of the week

Chapter 31: Assessment and Management of Patients With Hypertension - Page 865

91

A patient with long-standing hypertension is admitted to the hospital with hypertensive urgency. The physician orders a chest x-ray, which reveals an enlarged heart. What diagnostic test does the nurse anticipate preparing the patient for to determine left ventricular enlargement?

Echocardiography

Left ventricular hypertrophy can be assessed by echocardiography, but not by any of the other measures listed.

Chapter 31: Assessment and Management of Patients With Hypertension - Page 864

92

A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension?

Secondary

Secondary hypertension is elevated BP that results from or is secondary to some other disorder. This type of hypertension is not primary, essential, or malignant.

Chapter 31: Assessment and Management of Patients With Hypertension - Page 861

93

The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?

Heart and blood vessels

Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP= CO (cardiac output)× PR (peripheral resistance). To highlight the mechanism of cardiac output, a heart would be on the visual aid and blood vessels

Chapter 31: Assessment and Management of Patients With Hypertension - Page 655

94

A nurse is teaching a 38-year-old man with newly diagnosed hypertension who asks if there is any harm in stopping his antihypertensive medication if he decides to discontinue it. The correct reply addresses the consequence of stopping antihypertensive medications abruptly. Which of the following statements from the nurse would be appropriate?

"Rebound hypertension can occur."

Clients need to be informed that rebound hypertension can occur if they stop antihypertensive medications suddenly. This can be extremely dangerous and have serious consequences. Hypotension would not be a problem with discontinuation of antihyperstensive medications

Chapter 31: Assessment and Management of Patients With Hypertension - Page 872

95

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

"Limiting my salt intake to 2 grams per day will improve my blood pressure."

To lower blood pressure, a client should limit daily salt intake to 2 g or less. Alcohol intake is associated with a higher incidence of hypertension, poor compliance with treatment, and refractory hypertension. Chronic, moderate caffeine intake and fat intake don't affect blood pressure

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The nurse is caring for an 82-year-old male client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP?

Loss of arterial elasticity

In older clients, systolic BP may be elevated because of loss of arterial elasticity (arteriosclerosis). Systolic BP would not become elevated by a decrease in blood volume, an increase in calcium intake, or a decrease in cardiac output

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Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period.

140, 90

According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159, or a diastolic pressure of 90 to 99. Pressure of 130 systolic and 80 diastolic falls within the normal range for an adult. Pressure of 110 systolic and 60 diastolic falls within the normal range for an adult. Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult

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Which of the following client scenarios would be correct for the nurse to identify as a client with secondary hypertension?

A client diagnosed with kidney disease

Secondary hypertension is an elevated blood pressure that results from or is secondary to some other disorder such as kidney disease, a tumor of the adrenal medulla, or atherosclerosis. Depression alone is typically not associated with hypertension. Advanced age and alcohol intake are considered factors for essential hypertension

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It is appropriate for the nurse to recommend smoking cessation for patients with hypertension because nicotine

increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.

The nurse recommends smoking cessation for patients with hypertension because nicotine raises the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. Reduced oral fluids decrease the circulating blood volume.

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100

The nurse is creating a community teaching demonstration focusing on the cause of blood pressure. When completing the visual aid, which body structures represent the mechanism of blood pressure?

a) Brain and sympathetic nervous system
b) Lung and arteries
c) Kidneys and autonomic nervous system
d) Heart and blood vessels

Heart and blood vessels

Explanation: Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP= CO (cardiac output)× PR (peripheral resistance). To ... (more) Blood pressure is the force produced by the volume of the blood in arterial walls. It is represented by the formula: BP= CO (cardiac output)× PR (peripheral resistance). To highlight the mechanism of cardiac output, a heart would be on the visual aid and blood vessels.

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101

The nurse understands that patient education related to antihypertensive medication should include all of the following instructions except which of the following?

a) Avoid over the counter (OTC) cold, weight reduction, and sinus medications.
b) If a dosage of medication is missed, double up on the next one to catch up.
c) Avoid hot baths, exercise, and alcohol within 3 hours of taking vasodilators.
d) Do not stop antihypertensive medication abruptly.

If a dosage of medication is missed, double up on the next one to catch up

Explanation: Doubling doses could cause serious hypotension (HTN) and is not recommended. Medications should be taken as prescribed. Hot baths, strenuous exercise, and excessive alcohol are all ... (more) Doubling doses could cause serious hypotension (HTN) and is not recommended. Medications should be taken as prescribed. Hot baths, strenuous exercise, and excessive alcohol are all vasodilators and should be avoided. Many OTC preparations can precipitate HTN. Stopping antihypertensives abruptly can precipitate a severe hypertensive reaction and is not recommended.

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102

A systolic blood pressure of 135 mm Hg would be classified as which of the following?

a) Stage 2 hypertension
b) Stage 1 hypertension
c) Prehypertension
d) Normal

Prehypertension

Explanation: A systolic blood pressure of 135 mm Hg is classified as prehypertension. A systolic BP of less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg is stage I hypertension. ... (more) A systolic blood pressure of 135 mm Hg is classified as prehypertension. A systolic BP of less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg is stage I hypertension. A systolic BP of greater than or equal to 160 is classified as stage 2 hypertension

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A blood pressure of 140/90 mm Hg is considered to be

hypertension.

Explanation: A BP of 140/90 mm Hg or higher is hypertension. A blood pressure of less than 120/80 mm Hg is considered normal. A BP of 120 to 139/80 to 89 mm Hg is prehypertension. Hypertensive eme ... (more) A BP of 140/90 mm Hg or higher is hypertension. A blood pressure of less than 120/80 mm Hg is considered normal. A BP of 120 to 139/80 to 89 mm Hg is prehypertension. Hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage.

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Which of the following describes a situation in which blood pressure is very elevated but there is no evidence of impending or progressive target organ damage?

Hypertensive urgency

Explanation: Hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage. Secondary hypertension is high ... (more) Hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage. Secondary hypertension is high blood pressure from an identified cause, such as renal disease. Primary hypertension denotes high blood pressure from an unidentified source. A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage

Chapter 31: Assessment and Management of Patients With Hypertension - Page 873

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111

—Beta cells stimulated in pancreas to secrete insulin

—Used in type 2 diabetes to control blood glucose levels

—Not commonly used

—

—Side Effects

—Hypoglycemia

—Mild GI symptoms (abdominal upset)

—Weight gain

—Interactions with medications (NSAID’s, warfarin, sulfonamides)

—Skin reactions

—

—Examples: chlorpropamide (Diabinese), tolazamide (Tolinase), tolbutamide (Orinase)

First Generation Sulfonylureas

112

—Beta cells stimulated in pancreas to secrete insulin

—Used in type 2 diabetes to control blood glucose levels

—More potent effects than first generation sulfonylureas

—Can be used in combination with metformin or insulin to improve glucose control

—

—Side Effects

—Hypoglycemia

—Mild GI symptoms

—Weight gain

—Interactions with medications (NSAID’s, warfarin, sulfonamides)

—

—Examples: glipizide (Glucotrol), glyburide (Micronase, Diabeta), glimepiride (Amaryl)

—

—

SECOND GENERATION SULFONYLUREAS

113

—Inhibit production of glucose by the liver

—Increase body tissue sensitivity to insulin

—Decreases hepatic synthesis of cholesterol

—Used in type 2 diabetes for blood glucose control

—

—Side Effects

—Lactic Acidosis

—Hypoglycemia

—Interactions with medications

—GI disturbances

—Do not use in clients with impaired kidney/liver function, respiratory insufficiency, infection, or alcohol abuse.

—

—Examples: metformin (Glucophage, Fortamet), metformin with glyburide (Glucovance)

Biguanides

114

—Delays absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation

—Do not increase insulin secretion

—Used in type 2 diabetes to control blood glucose levels

—Can be only medication used or in combination with sulfonylureas, metformin, or insulin to improve glucose control

—

—Side Effects

—Hypoglycemia

—GI side effects

—Interactions with medications

—

—Examples: acarbose (Precose), miglitol (Glyset)

—

—

Alpha-Glucosidase Inhibitors

115

—Stimulate pancreas to secrete insulin

—Can be only medication used or in combination with metformin or thiazolidinediones to improve glucose control

—Side Effects

—Hypoglycemia

—Weight gain

—Interactions with medications (ketoconazole, erythromycin)

—

—Examples: repaglinide (Prandin)- meglitinide, nateglinide ( Starlix)- D-phenylalanine derivative

Non-Sulfonylurea Insulin Secretagogues

116

—Sensitizes body tissue to insulin; stimulate insulin receptor sites to lower blood glucose and improve action of insulin

—Can be only medication used or in combination with sulfonylureas, metformin, or insulin to improve glucose control

—

—Side Effects

—Hypoglycemia

—Anemia

—Weight gain, edema

—Oral contraceptives (decreased effectiveness)

—Possible liver dysfunction

— Interactions with medications

—Hyperlipidemia

—Impaired platelet function

—

—Examples: pioglitazone (Actos), rosiglitazone (Avandia)

Thiazolidinediones (or Glitazones)

117

—Increases and prolongs the action of incretin, a hormone that increases insulin release and decreases glucagon levels

—

—Side Effects

—Upper respiratory infection

—Stuffy or runny nose, sore throat

—Headache

—GI symptoms

—Hypoglycemia

—

—Examples: sitagliptin (Januvia), vildagliptin (Galvus)

Dipeptidyl Peptidase-4 (DDP-4) Inhibitors

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Onset: 5-15 minutes

Peak: 1-3 hr

Duration: 2-5hr

Indications: for rapid reduction of glucose levels, to treat postprandial hyperglycemia and prevent nocturnal hypoglycemia

5-10 min before meal

Rapid-acting: lispro (Humalog), aspart (Novolog)

119

Onset: 30min-1.5 hrs

Peak: 2-4 hr

Duration: 4-6 hr

Indication: 20-30 min before a meal

SHORT ACTING ( REGULAR)

120

Onset: 1-4 hr

Peak: 4-12 hr

Duration:16-20 hr

Indication: food with onset and peak

30-60min before first meal of the day/30-60min before dinner

INTERMIDIATE ACTING (NPR)

121

Onset: Gradual-1 hr

Peak: continuous

Duration: 24 hr

Indication: basa

Long acting (Basal): glargine (Lantus) and detemir (Levemir)

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Use and action of insulin

Symptoms of hypoglycemia and hyperglycemia

Required actions

Blood glucose monitoring

Self-injection of insulin

Insulin pump use

Teaching Patients Insulin Self-Management

NURSING ; PATIENT EDUCATION

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INSULIN SLIDING SCALE

<70 Initiate Hypoglycemia Protocol

70-130 0 units

131-180 2 units

181-240 4 units

241-300 6 units

301-350 8 units

351-400 10 units

>400 12 units and call MD

BS at 0745: 246

BS at 1145: 182

Doug is 47 year old man admitted to your medical unit with an ulceration on his right foot. His blood glucose level is 473. He tells you that he takes NPH insulin 40 units every morning and Regular ( Humulin R) insulin sliding scale with each meal and at bedtime.

Doug said his doctor told him to keep his glucose between 100 and 150. What is the normal range for blood glucose? Why didn’t the doctor recommend that Doug keep his glucose in the normal range?

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Why do you think this incident occurred at 4pm?

The hypoglycemia occurred at 4pm because of the combined effects of his R-insulin and N-insulin. The effect of the R-insulin He took before lunch was beginning to decline but were still relatively strong. In addition, the effect of the N-insulin taken in the morning was beginning to peak. The combination of both of these insulin effects caused the body to move too much glucose from the blood stream into body cells, which led to the hypoglycemia

When you enter his room to check his 4 p.m. vital signs, he complains of a headache, and he’s started sweating before you finish taking his vitals. Based on your nursing assessment, what do you suspect?

BS is 69

What nursing interventions should you implement?

125

The next day, when checking Doug’s 745am blood glucose, the results are 350. What are possible causes of Doug’s blood glucose to be so high? What interventions should you implement?

Hyperglycemia when waking up in the morning:

Dawn phenomenon: a normal glucose level until about 3am, glucose rises. Nocturnal surges of hormones creates a greater need for insulin

Change time of injection of evening intermediate insulin from dinner to bedtime

Insulin waning: progressive increase of blood glucose from bedtime to morning

Common with evening intermediate is giving before dinner; increase dinner or bedtime dose

Somogyi effect: nocturnal hypoglycemia with rebound hyperglycemia

Decrease evening dose or increase bedtime snack

126

Doug develops symptoms of gastroenteritis. What should you teach Doug about Sick Day Rules?

Take insulin (or oral meds as usual)

Test blood glucose and test urine ketones every 3-4 hours

May need to supplement doses of Regular every 3-4 hours

Unable to follow meal plan: substitute soft foods 6-8 times a day

Drink fluids (1/2 cup of regular soda or OJ, 1 cup of Gatorade)

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DIABETES MELLITUS

A group of diseases characterized by hyperglycemia due to defects in insulin secretion, insulin action, or both

Type I

Type II

Gestational

DM associated with other conditions or syndromes

Table 51-1, page 1418

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Insulin is an anabolic (storage) hormone

(FUNCTIONS OF DIABETES)

Transports and metabolizes glucose for energy

Stimulates storage of glucose in the liver and muscle as glycogen

Signals the liver to stop the release of glucose

Enhances the storage of dietary fat in adipose tissue

Accelerates transport of amino acids into cells

Inhibits the breakdown of stored glucose, protein, and fat

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Insulin producing beta cells in the pancreas are destroyed by an autoimmune process

Autoimmune response in which antibodies against normal tissue

Decrease insulin production, unchecked glucose production by the liver and fasting hyperglycemia; glucose from food cannot be stored in the liver

TYPE 1 DIABETES

130

Decreased sensitivity to insulin (insulin resistance) and impaired beta cell function results in decreased insulin production

The receptor sites on the cells become resistant to insulin; increase amounts of insulin is needed

TYPE 2 DIABETES

131

Type 1: not inherited but a genetic predisposition combined with immunologic and possibly environmental (viral) factors

Type 2: family history of diabetes, obesity, race/ethnicity, age greater than 45 years, previous identified impaired fasting glucose or impaired glucose tolerance, hypertension ≥ 140/90, HDL ≤ 35 and/or triglycerides ≥ 250, history of gestational diabetes or babies over 9 pounds

RISK FACTORS OF DIABETES

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Polyuria

Polydypsia

Polyphagia

Fatigue, weakness, vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, recurrent infections

Type 1 may have sudden weight loss, nausea, vomiting, and abdominal pain if DKA has developed

3 "P"S CLINICAL MANIFESTATIONS

133

Fasting blood glucose 126 mg/dL or more

Random glucose exceeding 200 mg/dL

HgbA1C: >6%

See Chart 51-3 page 1421

CLINICAL DIAGNOSIS DIABETES

134

Hypoglycemia

Diabetic ketoacidosis (DKA)

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS), aka hyperosmolar nonketotic coma or hyperglycemia hyperosmolar syndrome (HHS)

ACUTE COMPLICATIONS OF DIABETES

135

Abnormally low blood glucose level (below 70 mg/dL)

Causes include too much insulin or oral hypoglycemic agents, too little food, and excessive physical activity

Often occurs before meals, skipping snacks

Manifestations

Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, hunger

Central nervous system symptoms: inability to concentrate, headache, confusion, memory lapses, slurred speech, numbness of lips and tongue, irrational or combative behavior, double vision, drowsiness

Severe hypoglycemia may cause disorientation, seizures, and loss of consciousness

HYPOGLYCEMIA

136

HOW TO MANAGE HYPOGLYCEMIA?

Treatment must be immediate

Give 15 g of fast-acting, concentrated carbohydrate

Conscious patient

3 or 4 glucose tablets

4–6 ounces of juice or regular soda (not diet soda)

6–10 hard candies

2–3 teaspoons of honey

Unconscious patient/cannot swallow

25-50mL of dextrose 50% in water IV

Retest blood glucose in 15 minutes, retreat if >70 mg/dL or if symptoms persist more than 10–15 minutes and testing is not possible.

Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30–60 minutes.

137

Hospitalized patient

Overuse of sliding scale regular insulin, NPO status, delayed meal

NPO:

Eliminate the rapid acting insulin, decrease amount of intermediate acting insulin

Clear liquid:

Simple carbs

Enteral tube feedings:

Simple carbs

HYPOGLYCEMIA

138

Caused by an absence of or inadequate amount of insulin resulting in abnormal metabolism of carbohydrate, protein, and fat

Clinical features

Hyperglycemia

Dehydration

Acidosis

Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia, abdominal pain, nausea vomiting, acetone breath, hyperventilation with Kussmaul respirations, and mental status changes

Diabetic Ketoacidosis (DKA)

139

Blood glucose levels vary from 300–800 mg/dL

Severity of DKA is not related to blood glucose level

Ketoacidosis is reflected in low serum bicarbonate and low pH; low PCO2 reflects respiratory compensation

Ketone bodies in blood and urine

Electrolytes vary according to water loss and level of hydration

ASSESSMENT OF DKA

140

Rehydration with IV fluid

IV continuous infusion of regular insulin

Reverse acidosis and restore electrolyte balance

Note: rehydration leads to increased plasma volume and decreased K+, insulin enhances the movement of K+ from extracellular fluid into the cells

Monitor

Blood glucose and renal function/UO

EKG and electrolyte levels—Potassium

VS, lung assessments, signs of fluid overload

TREATMENT OF DKA

141

Hyperosmolality and hyperglycemia occur due to lack of effective insulin. Ketosis is minimal or absent.

Hyperglycemia causes osmotic diuresis with loss of water and electrolytes; hypernatremia, and increased osmolality occur.

Manifestations include hypotension, profound dehydration, tachycardia, and variable neurologic signs due to cerebral dehydration.

High mortality

Hyperglycemic Hyperosmolar Nonketotic Syndrome

142

Rehydration

Insulin administration

Monitor fluid volume and electrolyte status

Prevention

BGSM

Diagnosis and management of diabetes

Assess and promote self-care management skills

TREATMENT OF HHNS

143

Fluid overload

Large volume of fluids at rapid rate

Hypokalemia

Rehydration, increased urinary excretion, movement of potassium into cells from insulin administration

Cerebral edema

Occurs with rapid correction of hyperglycemia, resulting in fluid shifts

Potential Complications with DKA/HHS

144

Macrovascular complications

Accelerated atherosclerotic changes

Coronary artery disease, cerebrovascular disease, and peripheral vascular disease

Microvascular complications: capillary basement membrane thickening

Diabetic retinopathy, nephropathy

Neuropathic changes: capillary closure, demyelination of nerves

Peripheral neuropathy, autonomic neuropathies, hypoglycemic unawareness, neuropathy, sexual dysfunction

LONG TERM COMPLICATION OF DIABETES

145

Group of diseases that affect all nerves due to elevated blood glucose levels

Capillary membrane basement thickening and demyelination of nerves

Peripheral neuropathy: distal portions of the nerve; lower extremities

Burning sensation, paresthesia

Medical management: tricyclic antidepressant (duloxetrine), anti-seizure (gabapentin, pregabalin)

Autonomic neuropathies: cardiac, GI, renal

Hypoglycemic unawareness

Long-term complications Diabetic Neuropathies

146

The nurse is caring for a patient with a diagnosis of pericarditis. Where does the nurse understand the inflammation is located?

a) The heart’s muscle fibers
b) The exterior layer of the heart
c) The inner lining of the heart and valves
d) The thin fibrous sac encasing the heart

The thin fibrous sac encasing the heart

The heart is encased in a thin, fibrous sac called the pericardium, which is composed of two layers. Inflammation of this sac is known as pericarditis

Chapter 25: Assessment of Cardiovascular Function - Page 655

147

A 52-year-old female patient is going through menopause and asks the nurse about estrogen replacement for its cardioprotective benefits. What is the best response by the nurse?

a) “That’s a great idea. You don’t want to have a heart attack.”
b) “Current research determines that the replacement of estrogen will protect a woman after she goes into menopause.”
c) “Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy.”
d) “You need to research it and determine what you want to do.”

“Current evidence indicates that estrogen is ineffective as a cardioprotectant; estrogen is actually potentially harmful and is no longer a recommended therapy.”

In the past hormone therapy was routinely prescribed for postmenopausal women with the belief that it would deter the onset and progression of coronary artery disease (CAD). However, based on results from the multisite, prospective, longitudinal Women’s Health Initiative study, the American Heart Association (AHA) no longer recommends the use of hormone therapy as a prevention strategy for women. In the most recently published AHA guidelines for primary prevention of CAD in women, the use of hormone therapy (estrogen) is noted to be ineffective and potentially harmful

Chapter 25: Assessment of Cardiovascular Function - Page 660

148

Which term is used to describe the ability of the heart to initiate an electrical impulse?

a) Contractility
b) Automaticity
c) Conductivity
d) Excitability

Automaticity

Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse.

Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse.

Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another.

Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse

Chapter 25: Assessment of Cardiovascular Function - Page 657

149

The nurse is assessing the cardiovascular status of a client who was found unresponsive in a lobby area. Following transfer of the client, the family asks how blood circulates through the body. The nurse is most correct to state the proper circulation as which? Place the pattern of circulation in the correct order beginning in the right atrium. Use all options.

a) Pulmonary artery
b) Pulmonary vein
c) Left atrium
d) Right ventricle
e) Left ventricle
f) Aorta

• Pulmonary artery
• Pulmonary vein
• Left atrium
• Right ventricle
• Left ventricle
• Aorta

The pathway of blood flow from the right atrium includes the right ventricle. The blood flows to the lungs via the pulmonary artery and returns to the heart in an oxygenated state via the pulmonary vein. The oxygenated blood then enters the left atrium then left ventricle pump through the aorta to the systemic circulation

Chapter 25: Assessment of Cardiovascular Function - Page 656

150

You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels?

a) Platelets
b) WBC
c) RBC
d) Enzymes

Enzymes

When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage.

After an MI, RBCs and platelets should not be elevated.

WBCs would only be elevated if there was a bacterial infection present

Chapter 25: Assessment of Cardiovascular Function - Page 675

151

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should:

a) introduce a nasogastric (NG) tube.
b) position the client on his side.
c) insert an oral airway.
d) withhold food and fluids.

withhold food and fluids

Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns.

There's no indication that oral airway placement would be appropriate.

The client should be in the upright position, and the nurse needn't insert an NG tube

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152

The patient has a heart rate of 72 bpm with a regular rhythm. Where does the nurse determine the impulse arises from?

a) The AV node
b) The Purkinje fibers
c) The ventricles
d) The sinoatrial node

The sinoatrial node

The sinoatrial node, the primary pacemaker of the heart, in a normal resting adult heart has an inherent firing rate of 60 to 100 impulses per minute; however, the rate changes in response to the metabolic demands of the body

Chapter 25: Assessment of Cardiovascular Function - Page 657

153

After a physical examination, the provider diagnosed a patient with a grade 4 heart murmur. During assessment, the nurse expects to hear a murmur that is:

a) Easily heard with no palpable thrill.
b) Very loud; can be heard with the stethoscope half-way off the chest.
c) Quiet but readily heard.
d) Loud and may be associated with a thrill sound similar to (a purring cat).

Loud and may be associated with a thrill sound similar to (a purring cat

Heart murmurs are characterized by location, timing, and intensity. A grading system is used to describe the intensity or loudness of a murmur. A grade 1 is very faint and difficult to describe, whereas a grade 6 is extremely loud.

A grading system is used to describe the intensity or loudness of a murmur.

Grade 1: Very faint and difficult for the inexperienced clinician to hear

Grade 2: Quiet but readily perceived by the experienced clinician

Grade 3: Moderately loud

Grade 4: Loud and may be associated with a thrill

Grade 5: Very loud; heard when stethoscope is partially off the chest; associated with a thrill

Grade 6: Extremely loud; detected with the stethoscope off the chest; associated with a thrill

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154

The physician orders medication to treat a client’s cardiac ischemia. The nurse is aware that which of the following is causing the client’s condition?

a) Indigestion
b) Reduced blood supply to the heart
c) High blood pressure
d) Pain on exertion

Reduced blood supply to the heart

Ischemia is reduced blood supply to body organs. Cardiac ischemia is caused by reduced blood supply to the heart muscle. It may lead to a myocardial infarction.

Chest pain is a symptom of ischemia. Ischemia is reduced blood supply to body organs.

Ischemia is reduced blood supply to body organs

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155

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain?

a) Sound of the apical pulses
b) Pulse rate in upper extremities
c) Description of the pain
d) Blood pressure in the left arm

Description of the pain

If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the patient and measures vital signs. The nurse may measure BP in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities

Angina Pectoris

ACS (unstable angina, MI)

Angina:

Uncomfortable pressure, squeezing, or fullness in substernal chest area

Can radiate across chest to the medial aspect of one or both arms and hands, jaw, shoulders, upper back, or epigastrium

Radiation to arms and hands, described as numbness, tingling, or aching

Angina: 5–15 minAngina: Physical exertion, emotional upset, eating large meal, or exposure to extremes in temperatureAngina: Rest, nitroglycerin, oxygen ACS:

Same as angina pectoris

Pain or discomfort ranges from mild to severe

Associated with shortness of breath, diaphoresis, palpitations, unusual fatigue, and nausea or vomiting

ACS: >15 minACS:

Emotional upset or unusual physical exertion occurring within 24 h of symptom onset

Can occur at rest or while asleep

ACS:

Morphine, reperfusion of coronary artery with thrombolytic (fibrinolytic) agent or percutaneous coronary intervention

PericarditisSharp, severe substernal or epigastric pain

Can radiate to neck, arms, and back

Associated symptoms include fever, malaise, dyspnea, cough, nausea, dizziness, and palpitations

IntermittentSudden onset

Pain increases with inspiration, swallowing, coughing, and rotation of trunk

Sitting upright, analgesia, antiinflammatory medicationsPulmonary Disorders (pneumonia, pulmonary embolism)Sharp, severe substernal or epigastric pain arising from inferior portion of pleura (referred to as pleuritic pain)

Patient may be able to localize the pain

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A 97-year-old client with a history of atrial fibrillation is being admitted to the assisted living center where you practice nursing. In your initial assessment, you measure his apical pulse and compare it to his peripheral pulse. The difference between the two is known as what?

a) Pulse deficit
b) Pulse volume
c) Pulse rhythm
d) Pulse quality

Pulse deficit

To determine the pulse deficit, one nurse counts the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. The pulse quality refers to its palpated volume

Chapter 25: Assessment of Cardiovascular Function - Page 669

157

For both outpatients and inpatients scheduled for diagnostic procedures of the cardiovascular system, the nurse performs a thorough initial assessment to establish an accurate baseline data. Which of the following data is necessary to collect if the patient is experiencing chest pain?

a) Sound of the apical pulses
b) Description of the pain
c) Blood pressure in the left arm
d) Pulse rate in upper extremities

Description of the pain

If the patient is experiencing chest pain, a history of its location, frequency, and duration is necessary, as is a description of the pain, if it radiates to a particular area, what precipitates its onset, and what brings relief. The nurse weighs the patient and measures vital signs. The nurse may measure BP in both arms and compare findings. The nurse assesses apical and radial pulses, noting rate, quality, and rhythm. The nurse also checks peripheral pulses in the lower extremities

Chapter 25: Assessment of Cardiovascular Function - Page 662

158

The ability of the cardiac muscle to shorten in response to an electrical impulse is termed which of the following?

a) Repolarization
b) Diastole
c) Depolarization
d) Contractility

Contractility

Contractility is the ability of the cardiac muscle to shorten in response to an electrical impulse.

Depolarization is the electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell.

Repolarization is the return of the cell to the resting state, caused by reentry of potassium into the cell while sodium exits the cell.

Diastole is the period of ventricular relaxation resulting in ventricular filling

Chapter 25: Assessment of Cardiovascular Function - Page 660

159

Which of the following nursing interventions is most appropriate when caring for a client with a nursing diagnosis of risk for injury related to side effects of medication (enoxaparin [Lovenox])?

a) Assess for clubbing of the fingers.
b) Assess for hypokalemia.
c) Administer calcium supplements.
d) Report any incident of bloody urine, stools, or both.

Report any incident of bloody urine, stools, or both

The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both

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160

The nurse is providing discharge education for the client going home after a cardiac catheterization. Which of the following would be important information to give this client?

a) Do not ambulate until the physician indicates it is appropriate.
b) Expect bruising to appear at the site.
c) Avoid tub baths, but shower as desired.
d) Returning to work immediately is okay.

Avoid tub baths, but shower as desired

Guidelines for self-care after hospital discharge following a cardiac catheterization include shower as desired (no tub baths), avoid bending at the waist and lifting heavy objects, the physician will indicate when it is okay to return to work, and notify the physician right away if you have bleeding, new bruising, swelling, or pain at the puncture site

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161

The nurse correctly identifies which of the following data as an example of BP and HR measurements in a patient with postural hypotension?

a) Supine: BP 130/70 mm Hg, HR 80 bpm; sitting: BP 128/70 mm Hg, HR 80 bpm; standing: BP 130/68 mm Hg, HR 82 bpm
b) Supine: BP 114/82 mm Hg, HR 90 bpm; sitting: BP 110/76 mm Hg, HR 95 bpm; standing: BP 108/74 mm Hg, HR 98 bpm
c) Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm
d) Supine: BP 140/78 mm Hg, HR 72 bpm; sitting: BP 145/78 mm Hg, HR 74 bpm; standing: BP 144/78 mm Hg, HR 74 bpm

Supine: BP 120/70 mm Hg, HR 70 bpm; sitting: BP 100/55 mm Hg, HR 90 bpm; standing: BP 98/52 mm Hg, HR 94 bpm

Postural (orthostatic) hypotension is a sustained decrease of at least 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP within 3 minutes of moving from a lying or sitting to a standing position.

The following is an example of BP and HR measurements in a patient with postural hypotension: supine: BP 120/70 mm Hg, HR 70 bpm;

sitting: BP 100/55 mm Hg, HR 90 bpm;

standing: BP 98/52 mm Hg, HR 94 bpm.

Normal postural responses that occur when a person moves from a lying to a standing position include (1) a HR increase of 5 to 20 bpm above the resting rate; (2) an unchanged systolic pressure, or a slight decrease of up to 10 mm Hg; and (3) a slight increase of 5 mm Hg in diastolic pressure

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162

The nurse is caring for a client anticipating further testing related to cardiac blood flow. Which statement, made by the client, would lead the nurse to provide additional teaching?

a) “I had an ECG already. It provided information on my heart rhythm.
b) “My niece thought that I would be ordered a magnetic resonance imaging even though I have a pacemaker.”
c) “I am able to have a nuclide study because I do not have any allergies.”
d) “The first test I am getting is an echocardiography. I am glad that it is not painful.”

“My niece thought that I would be ordered a magnetic resonance imaging even though I have a pacemaker.”

A magnetic resonance imaging (MRI) test is prohibited on clients with various metal devices within their body. External metal objects must be removed. All other options are correct statements not needing clarification

Chapter 25: Assessment of Cardiovascular Function - Page 682

163

A patient in the ICU has a central venous pressure (CVP) line placed. The CVP reading is 10 mm Hg. The nurse would interpret this reading as being related to which of the following?

a) Reduction in preload
b) Left-sided heart failure
c) Hypervolemia
d) Right-sided heart failure

Right-sided heart failure

Normal CVP is 2 to 8 mm Hg.

A CVP greater that 8 mm Hg indicates hypervolemia or right-sided heart failure.

A CVP less than 2 mm Hg indicates a reduction in preload or hypovolemia

Chapter 25: Assessment of Cardiovascular Function - Page 687

164

A patient recently diagnosed with pericarditis asks his nurse to explain what area of his heart is involved. The nurse tells the patient that the pericardium, which is inflamed, is the:

a) Heart's muscle fibers.
b) Exterior layer of the heart.
c) Thin fibrous sac that encases the heart.
d) Inner lining of the heart and valves.

Thin fibrous sac that encases the heart

The pericardium is a thin, fibrous sac that encases the heart. It is composed of two layers, the visceral and the parietal pericardium. The space between these two layers is filled with fluid

Chapter 25: Assessment of Cardiovascular Function - Page 655

165

The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. The nurse makes it a priority to notify the physician for which of the following reasons?

a) These values show a risk for dysrhythmias.
b) The client is at risk for renal failure due to the contrast agent that will be given during the procedure.
c) The client is over-hydrated, which puts him at risk for heart failure during the procedure.
d) The client is at risk for bleeding.

The client is at risk for renal failure due to the contrast agent that will be given during the procedure

The contrast medium must be excreted by the kidneys. If there is already a degree of renal impairment (which these laboratory values indicate), the risk for contrast agent-induced nepropathy and renal failure is high

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166

1)ASSESS LOC & CAN SWALLOW

2)15 GRAMS FAST ACTION CARB (IE;OJ)

3)CHECK BLOOD SUGAR 15 MIN: INCREASED 70= 0 UNITS

4) 30 GRAMS FAST ACTING CARB(COMPLEX) W/ PROTEIN

NURSING INERVENTIONS DIABETES

167

Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition is through:

a) Laboratory tests
b) An MRI
c) Using a sphygmomanometer
d) Ophthalmic examination

no data


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