Exhibits

For each assessment finding, click to specify if the finding is consistent with diabetes, pancreatitis, or hyperthyroidism. Each client finding may support more than one disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Change in weight

Blood glucose

Current T3 level

Polyuria

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B"},"C":{"answers":"C"},"D":{"answers":"A,C"}}

Rationale:

Change in weight: In uncontrolled diabetes due to the breakdown of fat and muscle when insulin is insufficient to utilize glucose effectively. Chronic pancreatitis can cause weight loss due to malabsorption of nutrients from pancreatic insufficiency and ongoing inflammation. Increased metabolic rate in hyperthyroidism causes the body to burn calories rapidly, often resulting in significant, unintentional weight loss.
Blood glucose: A blood glucose level of 250 mg/dL is diagnostic of hyperglycemia and is strongly indicative of diabetes or poorly controlled blood glucose in a known diabetic. Inflammation of the pancreas can impair insulin production, leading to hyperglycemia, especially in chronic or severe pancreatitis.
Current T3 level: A T3 level of 200 mg/dL is at the upper limit of normal. In the presence of other symptoms like weight loss and polyuria, it may support a diagnosis of hyperthyroidism or subclinical hyperthyroidism.
Polyuria: High blood glucose levels exceed the renal threshold, leading to osmotic diuresis and frequent urination, a classic sign of diabetes. Increased metabolic activity and cardiac output in hyperthyroidism can lead to increased renal perfusion and mild diuresis, contributing to frequent urination.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Place a towel over the area to be percussed: A towel should be placed over the area to be percussed to protect the skin and to reduce discomfort. This is a standard procedure to ensure that the percussion is effective and comfortable for the client.

B. Ask the client to take shallow, rapid breaths: Shallow, rapid breaths should be avoided during chest percussion. The client should take deep, slow breaths to help mobilize secretions and allow for effective lung expansion. Rapid breathing could increase respiratory distress.

C. Percuss over each area for 10 min: Percussion should not be performed for 10 minutes over each area, it is done for 1-2 minutes over each lung field to help loosen mucus and improve drainage. Prolonged percussion could be harmful and unnecessary.

D. Maintain client positioning for 45 min: Typically, positioning is maintained for short periods (usually 10-15 minutes) depending on the area being targeted for percussion. Prolonged positioning may lead to discomfort or other complications.

A. Increased joint pain B. Increased body temperature C. Cool, moist extremities D. Small blisters on the skin

Correct Answer is D

Explanation

A. Increased joint pain: Joint pain is not a typical sign of overexposure to phototherapy. While psoriatic arthritis can occur in individuals with psoriasis, it is not directly linked to phototherapy overexposure.

B. Increased body temperature: While phototherapy may slightly raise the body's temperature, a significant increase in body temperature is not a typical indication of overexposure. This could suggest another underlying issue, such as infection or heatstroke.

C. Cool, moist extremities: Cool, moist extremities are not typically associated with phototherapy overexposure. This finding is more indicative of circulatory or other systemic issues, which do not directly result from phototherapy.

D. Small blisters on the skin: Small blisters on the skin are a common sign of overexposure to phototherapy. Phototherapy uses ultraviolet (UV) light, and excessive exposure can lead to skin damage, including burns or blisters, similar to sunburn.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing chest percussion on a client who has severe COPD. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving phototherapy for psoriasis. Which of the following findings should the nurse identify as an indication of overexposure?

Correct Answer is D

Explanation

A nurse is assessing a client who has disseminated intravascular coagulation. Which of the following findings should the nurse expect?

A nurse is teaching a group of clients who plan to receive the human papillomavirus (HPV) Immunization. Which of the following statements by a group member indicates an understanding of the teaching?

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