Which nursing diagnosis is of the highest priority for the patient presenting with hyperosmolar hyperglycemic syndrome (HHS)?
1. Altered Nutrition: More than Body Requirement
2. Deficient Fluid Volume
3. Noncompliance related to self-management
4. Knowledge Deficit related to diabetic diet
2
Rationale 1: The etiology of HHS is not related to overeating.
Rationale 2: The patient with HHS typically has blood glucose levels >600 mg/dL, which leads to profound osmotic diuresis and dehydration. This syndrome may develop more frequently in type 2 diabetics who are ill and have unreplaced fluid losses.
Rationale 3: Noncompliance with self-management is too broad a category to address in a critically ill patient.
Rationale 4: While proper diet is important in diabetes management, dietary indiscretion is not the main cause of HHS.
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The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is 2.0 mg/dL. Based on this data, which nursing intervention would address this client's phosphorus level?
A) Enforce contact precautions. B) Encourage consumption of a high-calorie carbohydrate diet. C) Strain all urine. D) Encourage consumption of milk and yogurt.
The nurse is providing education to a client about the most common causes of goiters. Which causative factor will the nurse review in the teaching?
A) Thyroiditis B) Tumors C) Iodine deficiency D) Infiltrative
Phenytoin (Dilantin) has a narrow therapeutic index. The nurse recognizes that this characteristic indicates which of these?
a. The safe and the toxic plasma levels of the drug are very close to each other. b. The phenytoin has a low chance of being effective. c. There is no difference between safe and toxic plasma levels. d. A very small dosage can result in the desired therapeutic effect.
A patient tells the nurse that he does not understand the surgical procedure the health care provider told him he needed. Which of the following should the nurse do to advocate for this patient?
1. Contact the health care provider and ask that the procedure be explained to the patient. 2. Explain the procedure to the patient. 3. Document that the patient does not understand the proposed surgical procedure. 4. Instruct the patient in alternatives to the surgical procedure.